COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX00035068 


./ 


Cotumbm  WLnibtx&ity 
tntteCttpofi^eto|9orfe 

Reboot  of  Cental  anb  &va\  burger? 


Reference  Etfararp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/fracturesbycarlbOObeck 


Fracture  of  the  tibia.  Case  illustrated  by  figure  139.  Callus-formation  two 
weeks  after  the  injury.  The  anode  was  placed  directly  above  the  fractured  area. 
The  left  leg  was  resting  on  the  floor.  The  right  leg  was  placed  laterally,  but,  being 
supported,  it  was  brought  on  a  level  with  the  anode.  Thus  it  appears  much  the 
larger  in  proportion. 


FRACTURES 


BY 


CARL  BECK,  M.D. 

VISITING    SURGEON    TO    ST.    MARK'S    HOSPITAL    AND    TO    THE    NEW    YORK    GERMAN 

POLIKLINIK;    FORMERLY    PROFESSOR   OF   SURGERY,   NEW   YORK   SCHOOL   OF 

CLINICAL   MEDICINE:    CONSULTING    SURGEON,   SHELTERING 

GUARDIAN   SOCIETY   ORPHAN    ASYLUM,    ETC. 


WITH    AN 

APPENDIX 

ON  THE  PRACTICAL  USE  OF  THE  RONTGEN  RAYS 


178    ILLUSTRATIONS 


ff 


CJ&o-<^,  ux UZ) 


'Quidquid  latet,  adparebit, 
Nil  occultum  remanebit." 


PHILADELPHIA 

W.   B.  SAUNDERS  &  COMPANY 
i  goo 


CM0\ 


Copyright,  1900,  by  W.  B.  Saunders  &  Company. 


TO 

Wtlbelm  Conrafc  iRontgen, 

WITHOUT  WHOSE   DISCOVERY  MUCH   OF  THIS  BOOK  COULD 
NOT   HAVE   BEEN   WRITTEN. 


PREFACE. 


During  the  past  few  years  literature  on  the  Rontgen  ray 
has  grown  to  large  proportions.  It  has  led  to  many  and 
revolutionizing  discoveries ;  most  of  these  have  marked  a 
clearer  understanding,  and  consequently  the  better  treatment, 
of  fractures.  Still,  publications  on  this  subject  hitherto  have 
not  claimed  to  be  more  than  tentative  sketches  or  preliminary 
communications. 

This  book  is  an  effort  to  encompass  in  a  systematic  treatise 
the  important  essentials  of  the  publications  on  this  subject  and 
such  individual  studies  and  experience  as  it  has  fallen  to  my 
lot  to  make.  In  these  studies  the  Rontgen  ray  has  verified 
the  anatomic  findings.  It  did  so  by  exposing  the  fractures 
in  their  living  state. 

The  illustrations  in  older  works  were  mainly  made  from  the 
cadaver.  The  splendid  schematic  representations  that  resulted 
were  not  portraits  from  life.  The  minute  arrangement  and 
disarrangement  of  fragments  and  splinters,  especially  in  their 
relations  to  the  joints,  were  necessarily  disarranged  by  even 
the  most  careful  dissections.  The  Rontgen  ray  depicts  these 
details  and  all  others  undisturbed  and  as  they  are  in  life.  // 
is  with  tJicsc  that  the  surgeon  has  to  deal. 

Before  Rontgen's  epoch-making  discovery  it  was  just  and 
proper  to  associate  all  studies  of  fractures  with  those  of  dislo- 
cations. The  essential  aim  of  this  association  necessarily  was 
for  purposes  of  differential  diagnosis.  Now,  however,  the 
student,  made  familiar  with  the  various  types  of  fracture,  has 
no  difficulty  in  recognizing  and  appreciating  the  various  forms 
of  dislocation.  Moreover,  the  greater  importance  of  the 
former  is  evident  in  the  fact  that  fractures  occur  no  less  than 

5 


6  PREFACE. 

ten  times  as  frequently  (a  longer  experience  with  the  Rontgen 
ray  will  probably  make  it  fifteen  times)  as  do  dislocations. 
Furthermore,  the  after-treatment  of  fractures  must  be  pre- 
dicated upon  a  thorough  recognition  of  the  anatomic  rela- 
tions of  the  line  of  solution  of  osseous  continuity,  while  in 
dislocations  the  therapy  after  reduction  is  very  simple.  Neces- 
sarily, the  differentiation  of  the  more  frequent  luxations,  that 
closely  resemble  fractures,  has  received  considerable  attention 
in  these  pages. 

All  the  common,  and  some  of  the  rarer,  types  of  fracture 
are  represented  skiagraphically.  The  skiagrams  and  most  of 
the  drawings  here  presented  are  originals.  They  depict  cases 
observed  and  treated  in  my  dispensary,  hospital,  and  private 
practice.  Some  illustrations  are  copied  from  Hoffa,  von  Berg- 
mann,  Oilier,  Nelaton,  and   Lejars. 

The  skiagrams  are  exact  reproductions  of  photographic 
prints.  I  resisted  the  temptation  to  emphasize  their  essential 
points  by  artistic  interference,  so  that  they  represent  the  skia- 
graphic  findings  precisely  as  they  are,  with  the  exception  of 
figures  107,  122,  151,  and  169,  in  which  the  important  points 
were  lost  during  the  process  of  reproduction.  Figure  75  is 
treated  schematically. 

It  affords  me  special  pleasure  to  here  thank  Professor  Ront- 
gen for  the  many  kindnesses  of  which  I  have  been  the  re- 
cipient at  his  laboratory.  My  sincere  acknowledgments  are 
also  due  to  Professors  von  Bergmann  and  Koerte,  to  Surgeon- 
General  Stechow,  of  Berlin,  and  to  Professors  Hoffa  and  Gocht, 
of  Wiirzburg,  for  many  courtesies. 

The  skiagraphic  plates  were  developed  by  Mr.  Joseph 
Byron,  whom  I  desire  to  thank  for  his  painstaking  work. 

It  also  affords  me  pleasure  to  acknowledge  my  obligations 
to  the  publishers,  W.  B.  Saunders  &  Company,  for  the  typo- 
graphic and  pictorial  excellence  of  this  book. 

Carl  Beck. 

J7  East  j  1 st  Street,  ATew  York. 


CONTENTS 


PAGE 

Introduction 9 

PART   I. 
FRACTURES   IN   GENERAL. 

Classification  of  Fractures 17 

Statistics 20 

Signs 21 

Diagnosis      23 

The  Process  of  Repair  and  the  Formation  of  Callus 26 

Disturbances  in  the  Process  of  Repair ,  31 

Treatment 34 

Peculiarities  of  Fractures  in  Children 73 

PART  II. 
FRACTURES  OF    SPECIAL    REGIONS. 

Fractures  of  the  Shoulder  and  the  Upper  Extremity 78 

Clavicle 78 

Scapula 89 

Humerus 92 

Forearm 121 

Hand  and  Fingers 161 

Fractures  of  the  Pelvis  and  the  Lower  Extremity 166 

Pelvis 166 

Thigh 168 

Patella 193 

Leg 204 

Foot 226 

Fractures  of  the  Bones  of  the  Trunk 232 

Ribs 1 232 

Sternum 238 

Spinal  Column 238 

Fractures  of  the  Skull 247 

Vertex 248 

P>ase 265 

Facial  Bones 26S 

APPENDIX. 

The  Practical  Use  of  the  Rontgen  Rays 277 

Errors  of  Skiagraphy 311 

Index 329 


INTRODUCTION. 


Few  scientific  discoveries  of  the  century  have  aston- 
ished the  world  more  than  that  reported  by  Wilhelm 
Conrad  Rontgen,  of  Wiirzburg-on-the-Main.  The  sig- 
nificance of  this  great  discovery  can  not  even  yet  be 
estimated. 

The  preparatory  researches  that  led  to  this  dis- 
covery date  from  the  time  when  Maxwell,  extending 
and  applying  Faraday's  theories,  found  that  the  phe- 
nomena of  electricity  depend  upon  the  same  principles 
as  those  of  light.  Both  consist  in  vibrations  of  the 
ether  that  pervades  the  universe.  Wiedemann,  Yer- 
det,  Kundt,  Gassiot,  Spottiswoode,  and  Rontgen  tried 
to  prove  that  the  phenomena  of  electricity  are  in  close 
connection  with  those  of  light,  and  not  only  that  elec- 
tricity could  produce  light,  but  also  that  light  could 
produce  electricity. 

The  correctness  of  these  theories,  however,  could 
not  be  proved  until  the  experiments  of  Wilhelm 
Hertz,  a  professor  at  the  University  of  Bonn,  brought 
conviction  to  the  minds  of  even  the  most  skeptical. 
Hertz  showed  that  electric  induction  obeys  the  same 
laws  as  those  governing  the  diffusion  of  light-waves. 
He  also  determined  the  speed  of  transmission  of  the 
electric  wave,  which  he  found  to  be  equal  to  that  of 
the  light-wave. 

The  phenomena  of  electric  discharge  in  closed  tubes, 
showing  various  degrees  of  exhaustion  and  filled  with 


IO  INTRODUCTION. 

different  gases,  had  been  the  subject  of  experiment  for 
many  years,  and  a  marked  difference  was  noticed 
between  the  phenomena  of  light  at  the  two  electric 
poles.  Light  radiating  from  the  positive  pole  extends 
entirely  through  a  vacuum  tube  ;  while  light  radiating 
from  the  negative  pole  produces  only  a  very  weak 
and  diffused  illumination.  But  as  soon  as  the  vacuum 
is  increased  to  a  high  degree,  the  phenomena  become 
entirely  different.  The  light  of  the  positive  pole  de- 
creases, while  that  of  the  negative  pole  pervades  the 
vacuum  more  and  more,  being  permanently  propa- 
gated in  straight  lines. 

The  light  emanating  from  the  negative  pole  is  called 
the  "  cathode-ray y  Lenard  and  Hittorf  found  that 
such  rays  have  the  power  of  creating  fluorescence, 
heat,  etc.,  and  that  they  can  be  deflected  by  a  magnet. 
The  vacuum-tube  that  is  commonly  used  is  generally 
called  the  Crookes  tube,  after  Sir  William  Crookes, 
who  described  and  slightly  modified  the  tube.  The 
credit  for  having  originally  devised  it  is  due  to  Geiss- 
ler,  an  ingenious  mechanician  of  Bonn,  Germany. 

As  soon  as  an  electric  current  of  high  intensity  goes 
through  the  conducting  wires  fused  into  the  ends  of 
the  tube,  the  negative  electrode,  or  cathode,  becomes 
surrounded  by  a  faint  dark-blue  light,  while  the  posi- 
tive electrode,  the  anode,  sends  a  peach-colored  light 
through  the  tube  as  far  as  the  light  of  the  cathode. 
As  the  air  is  gradually  rarefied,  the  positive  stream  of 
light  almost  disappears,  while  the  negative  cathode 
light  extends  more  and  more,  and  finally  fills  the  whole 
tube. 

In  December,  1895,  Rontgen,  while  experimenting 
with  these  tubes  by  surrounding  them  with  black  paste- 
board, impermeable  by  light,  discovered  an  astonish- 


INTRODUCTION.  I  I 

ing  phenomenon.  On  a  screen  standing  near  the  tube, 
and  painted  with  a  light  color  (barium  platinocyanid), 
he  noticed  a  light  as  soon  as  an  electric  current  went 
through  the  tube.  It  became  evident  at  once  that 
there  was  a  radiant  power  that,  although  not  percepti- 
ble to  the  eye,  permeated  the  pasteboard.  This  force, 
heretofore  unknown,  also  showed  a  marked  effect  on 
the  screen.  Rontgen,  after  having  found  that  the 
effect  of  these  invisible  rays  upon  the  screen  was  con- 
stant, tried  photographic  experiments  also.  He  then 
discovered  that  under  the  influence  of  these  rays  his 
hand,  resting  upon  the  cover  of  a  wooden  box,  gave  a 
sharp  silhouette  on  a  drying  plate  below,  although  the 
cover  was  not  removed.  He  also  found  that  paper, 
wood,  and  even  thin  discs  of  metal,  were  permeable 
by  the  rays,  while  thick  discs  of  metal,  bones,  etc., 
produced  silhouettes.  This  latter  discovery,  in  particu- 
lar, at  once  aroused  the  most  wide-spread  interest  in 
regard  to  its  uses  in  surgery,  and  up  to  the  present 
date  its  full  significance  can  hardly  be  appreciated. 
Rontgen  modestly  suggested  naming  the  new  rays 
"X-rays,"  until  their  nature  should  be  discovered;  but 
Professor  Kolliker,  of  Wiirzburg,  very  properly  pro- 
posed calling  them  "Rontgen  rays,"  and  the  veteran 
scientist's  recommendation  will  probably  be  followed 
by  men  of  science  and  by  the  profession. 

The  proofs  of  the  great  usefulness  of  the  rays  in  sur- 
gery are  now  so  overwhelming  that  to  discuss  them 
would  be  carrying  owls  to  Athens.  Their  value  in  in- 
ternal medicine  has  not  as  yet  been  made  so  apparent ; 
still,  much  has  been  contributed  in  this  field,  and  there 
can  be  no  doubt  that,  with  the  better  interpretation  of 
the  shadows  and  the  continuous  improvement  of  diag- 
nostic technic,  the  significance  of  the  rays  in  many  of 


I  2  INTRODUCTION. 

the  obscurer  ailments  will  be  convincing  to  the  mind 
of  the  most  skeptical. 

The  greatest  usefulness  of  the  rays  thus  far  displayed 
is,  however,  in  the  recognition  of fractures.  Accuracy 
takes  the  place  of  ignorance  and  doubt,  and  painful 
manipulations  cease  to  be  necessary  for  diagnostic  pur- 
poses. Even  the  most  skilful  experts  in  fractures 
are  unable  to  deny  that  there  is  a  large  number  of 
bone-injuries  the  character  of  which  formerly  could  not 
be  recognized,  whether  on  account  of  the  swelling  of 
the  area  involved  or  from  the  obscurity  of  the  symp- 
toms. The  number  of  cases  of  fracture  formerly  mis- 
taken for  contusion  or  distortion  was  enormous.  It  is 
in  such  cases  that  a  simple  glance  with  the  fluoroscope 
furnishes  the  most  precise  evidence.  Whether  there 
is  comminution  or  impaction  or  the  intervention  of 
muscular  tissue  or  intra-articular  fracture  or  combi- 
nation with  a  dislocation,  can  be  at  once  clearly  de- 
termined. If  the  picture  be  fixed  on  a  photographic 
plate,  the  nature  of  the  injury  can  be  studied  at  leisure, 
and  the  proper  line  of  treatment  easily  decided  upon 
without  subjecting  the  patient  to  any  tentative  manipu- 
lations. After  a  dressing  is  applied,  the  skiagram 
verifies  the  proper  position  of  the  fragments.  In  fact, 
the  proper  execution  of  all  therapeutic  points  can  be 
verified  throughout  the  course  of  treatment  by  the  skia- 
gram, the  dressing  itself,  even  if  consisting  of  plaster- 
of-Paris,  being  no  obstacle  to  the  rays. 

Even  the  shoemaker  can  profit  by  the  rays,  which 
will  prove  whether  shoes  fit  accurately — an  item  of 
great  importance  in  the  after-treatment  of  fractures  or 
in  club-foot. 

If  the  therapy  proves  to  be  imperfect,  the  rays  show 
the  nature  of  the  condition.     It  is  easily  determined, 


INTRODUCTION.  I  3 

for  instance,  whether  an  ankylosis  be  fibrous  or  os- 
seous; and,  consequently,  the  question  whether  the 
breaking-up  of  adhesions  or  resection  is  indicated  is 
settled  at  once. 

It  is  needless  to  call  attention  to  the  frequent  im- 
portance of  a  skiagraphic  proof  in  court,  for  the  pro- 
tection of  the  surgeon  as  well  as  of  the  patient. 

The  greatest  benefit  obtained  from  the  rays,  in  the 
proper  judgment  of  the  various  types  of  fractures,  is 
in  connection  with  those  situated  in  the  neighborhood 
of  joints.  The  special  uses  of  the  rays  in  diagnosticat- 
ing the  various  types  of  fracture  may  be  grouped  as 
follows  : 

Fractures  of  the  clavicle  are,  in  general,  easily  rec- 
ognized without  the  rays.  Still,  there  are  rare  cases 
of  infraction  and  fissure  in  which  no  deformity  or  crepi- 
tus is  observable,  and  which  could  not  be  recognized 
except  by  the  aid  of  the  rays. 

In  fractures  of  the  scapula  the  conditions  are  often 
so  obscure  that  without  skiagraphy  the  true  nature  of 
the  injury  may  be  veiled  ;  for  instance,  when  disloca- 
tion of  the  humerus  is  combined  with  fracture  of  the 
acromion. 

In  fractures  of  the  humeriis  it  is  the  shoulder-joint 
and  elbow-joint  that  require  the  use  of  the  rays  most 
frequently.  Especially  in  reference  to  the  elbow-joint, 
it  may  be  safely  asserted  that  an  exact  diagnosis  with- 
out skiagraphy  is  simply  impossible  in  by  far  the  great 
majority  of  cases.  Skiagraphy  will  infallibly  demon- 
strate the  various  types  of  elbow-fractures  ;  it  will,  fur- 
thermore, show  whether  the  line  of  fracture  is  transverse 
or  T-shaped,  and  whether  there  are  any  complications, 
such,  for  instance,  as  a  fracture  of  the  olecranon  com- 
bined with  dislocation  of  the  radius. 


14  INTRODUCTION. 

In  fractures  of  the  forearm  it  is  the  elbow-joint  and  the 
wrist-joint  that  especially  require  the  use  of  these  rays. 
In  these  cases  as  well  as  in  those  previously  noted  a 
large  number  of  new  facts  have  been  revealed,  which 
have  entirely  revolutionized  our  pathologic  and  thera- 
peutic views. 

Fractures  of  the  bones  of  the  hand  occur  much  more 
frequently  than  was  formerly  supposed.  Fractures  of 
the  individual  carpal  and  metacarpal  bones,  and  even 
of  the  phalanges,  were  often  mistaken   for  contusions. 

Fractures  of  the  pelvis,  the  accurate  recognition  of 
which  formerly  offered  the  greatest  difficulties,  can  also 
be  readily  demonstrated — the  differentiation  between 
contusion,  fracture  of  the  acetabulum  or  of  the  neck  of 
the  femur,  and  dislocation  especially  coming  into  ques- 
tion. Most  valuable  information  can  also  be  obtained 
as  to  the  presence  of  impaction. 

In  fracture  of  the  femur  it  is  not  only  the  hip-joint 
that  may  require  the  use  of  the  rays,  but  also  the 
shaft  and  the  lower  end  of  the  bone.  In  the  neighbor- 
hood of  the  knee-joint  rapid  swelling  often  absolutely 
prevents  an  accurate  diagnosis  except  when  the  rays 
are  employed.  Furthermore,  in  all  the  different  intra- 
articular complications  the  occurrence  of  epiphyseal 
separation,  and  the  question  as  to  the  transverse  or 
oblique  or  T-shaped  line  of  fracture  can  easily  be 
settled. 

Fracture  of  the  patella  can  easily  be  recognized  with- 
out the  aid  of  the  rays.  Still,  there  are  some  impor- 
tant questions — for  instance,  as  to  whether  the  fracture 
is  complete  or  incomplete,  or  whether  there  are  several 
fracture-lines — that  could  not  be  determined  without 
the  aid  of  the  rays.  It  goes  without  saying  that  in  the 
proper  determination  of  the  after-treatment,  in  the  cor- 


INTRODUCTION.  I  5 

rect  restoration  of  the  fragments,  and  in  the  confirma- 
tion of  the  result  in  the  event  of  wiring,  skiagraphic 
control  is  simply  indispensable. 

In  fracture  of  the  leg  the  difficulties  were  often  in- 
superable before  the  discovery  of  the  rays.  It  is 
especially  in  the  malleolar  type  that  serious  distur- 
bances are  observed.  Especially  in  regard  to  the  so- 
called  Pott's  fracture,  many  fresh  facts  were  revealed 
by  the  rays,  so  that,  just  as  in  fracture  of  the  lower  end 
of  the  radius,  our  former  views  have  been  changed 
completely. 

The  number  of  fractures  of  the  ankle  treated  as 
sprains  and  dislocations,  to  the  great  disadvantage  of 
the  patient  as  well  as  of  the  surgeon,  is  legion. 

Fracture  of  the  foot  is  also  found  to  be  more  frequent 
than  was  formerly  supposed.  Individual  fractures  of 
the  tarsal  and  metatarsal  bones  and  of  the  phalanges 
were  often  erroneously  taken  for  contusions.  Stechow 
has  found  that  the  so-called  edema  of  the  foot,  so  fre- 
quently found  among  the  German  infantry,  is  always 
due  to  a  badly  united  fracture  of  a  metatarsal  bone. 

In  fracture  of  the  ribs  and  of  the  sternum  skiagraphy 
will  often  prove  to  be  useful  from  the  standpoint  of 
jurisprudence. 

In  fracture  of  the  vertebra  the  exact  location  of  the 
fragments  is  of  great  importance  in  determining  the 
advisability  of  operating. 

In  fractures  of  the  skull,  those  of  the  face  and  of  the 
inferior  maxilla  have  derived  the  most  benefit  from  the 
rays.  Fractures  of  the  base  are  still  with  difficulty 
demonstrated. 

In  fracture  of  the  larynx  the  question  of  differentia- 
tion is  easily  settled  by  the  rays. 


PART   I. 
FRACTURES   IN   GENERAL. 


CLASSIFICATION  OF  FRACTURES. 

A  fracture  (a  word  derived  from  the  Latin  fran- 
gere,  "to  break")  is  a  solution  in  the  continuity  of  a 
bone.  It  is  either  traumatic — that  is  to  say,  produced 
by  violence — or  spontaneous,  caused  by  disease. 

Spontaneous  fractures  may  occur  on  account  of 
a  pathologic  fragility  of  the  bones  (osteopsathyrosis), 
which  may  be  due  to  tumors  (enchondroma,  sarcoma, 
metastatic  carcinoma,  echinococcus  cysts,  etc.),  or  to 
inflammatory  processes  (caries,  osteomyelitic  necrosis, 
osteosarcoma,  rachitis,  etc.),  or  to  constihitional  dis- 
eases, such  as  syphilis  and  scurvy.  Other  cases  are 
caused  by  disturbances  of  nutrition  of  the  bones.  Spinal 
diseases — syringomyelia,  tabes — are  also  occasional 
causes. 

In  this  book  the  traumatic  fractures  of  healthy  bones 
will  alone  be  considered. 

Traumatic  fractures  are  either  direct  or  indirect. 

A  direct  fracture  is  one  occurring  at  that  point  of 
the  bone  to  which  a  force  has  been  applied.  It  is 
obvious  that  this  type  bears  a  more  serious  character 
than  one  caused  by  indirect  violence,  since  an  injury 

2  17 


1 8  FRACTURES    IN    GENERAL. 

to  the  soft  tissues  covering  the  point  of  fracture  is 
added. 

An  indirect  fracture  is  one  that  occurs  at  a  point 
distant  from  that  where  the  force  has  been  applied. 
A  good  example  is  a  fracture  of  the  lower  end  of  the 
humerus  produced  by  a  fall  upon  the  hand. 

Sometimes  a  fracture  is  caused  by  muscular  contrac- 
tion. The  seats  of  predilection  for  this  variety  are  the 
olecranon,  humerus,  clavicle,  os  calcis,  tibia,  patella, 
and  femur. 

Traumatic  fractures  are  also  divided  into  simple  and 
compound. 

In  simple  fractures  the  bone  is  broken  at  one  point, 
and  no  communication  with  the  external  air  exists 
{subcutaneous) . 

In  compound  fractures  the  bone  is  broken  at  one  or 
more  points  and  communication  with  the  external  air 
exists. 

According  to  the  degree  of  separation  in  the  con- 
tinuity of  the  bone,  distinction  has  also  to  be  made 
between  complete  and  incomplete  fractures. 

According  to  the  direction  of  the  fracture,  complete 
fractures  are  either  transverse,  oblique,  longitudinal  or 
spiral. 

Thus,  according  to  the  displacement  taking  place 
after  the  fracture  is  sustained,  four  different  types  of 
a  complete  fracture  may  be  noted  :  viz. — 

i.  Lateral  displacement,  characterized  by  the  line  of 
separation  being  at  a  right  angle  to  the  long  axis  of 
the  bone  (rare  in  adults).      (Fig.  92.) 

2.  Axial  displacement,  in  which  the  line  of  separa- 
tion is  at  an  acute  angle  to  the  long  axis.   (Fig.  89.) 

3.  Longitudinal  displacement,  when   the  separation- 


CLASSIFICATION    OF    FRACTURES.  I  9 

line  is  parallel  to  the  long  axis.  If  there  is  axial  dis- 
placement the  so-called  riding  of  the  fragments  takes 
place.  It  is  often  observed  in  fractures  at  the  upper 
third  of  the  femur.      (Figs.  112,  114.) 

4.  Peripheral  displacement,  in  which  the  fragment  is 
turned  around  the  long  axis  of  the  bone  (torsion). 
(This  variety  may  occur  when  the  body  is  turned  while 
the  extremity  is  fixed.) 

If  in  a  complete  fracture  small  bone-fragments  are 
either  partly  or  totally  severed  from  the  bone,  it  is 
called  a  comminuted  fracture.      (Fig.  136.) 

If  the  bone  is  broken  at  several  points,  it  becomes  a 
multiple  fracture.     (Fig.  40.) 

If  a  fragment  consisting  of  compact  bone  is  forced 
into  the  substance  of  a  cancellated  one,  an  impacted 
fracture  is  produced.      (Fig.  107.) 

If  the  fracture  is  caused  by  a  bullet,  it  is  called  a 
gunshot  fracture.  The  bullet  of  the  army  weapon 
known  as  the  Krag-Jorgensen  rifle  produces  extensive 
splintering  of  the  diaphysis  of  the  long  bones  up  to  a 
distance  of  800  yards.  (Fig.  1 36.)  This  type  of  fracture 
may  also  be  incomplete. 

In  incomplete  fractures,  which  are  mostly  observed 
in  very  flexible  bones,  the  convex  corticalis  yields  and 
tears,  while  the  concave  stratum  is  only  bent.  This 
injury  is  called  infraction  (Figs.  92,  137);  it  maybe 
compared  to  the  bending  and  partial  splintering  of  a 
green  stick,  and  is  mainly  observed  in  childhood.  Its 
predilection  is  for  the  deformed  legs  of  rachitic  chil- 
dren, but  it  may  occur  in  old  individuals,  where  senile 
atrophy  has  caused  a  diminution  of  the  organic  sub- 
stance of  the  bones.  It  is  also  found,  as  a  result  of 
abnormal  uterine  contractions,  as  an  intrauterine  frac- 


20 


FRACTURES    IN    GENERAL. 


ture.  There  may  be  only  a  linear  division,  without  any 
displacement  or  disfiguration  of  the  external  shape  of 
the  bone  ( fissure).   (See  Figs,  i  and  2.)     This  variety  is 


Fig.    I. — Intrauterine   fracture   of  radius   and 
ulna  (outer  view). 


Fig.  2.  —  Intrauterine 
fracture  of  radius  and  ulna. 
Skiagram  taken  four  weeks 
after  birth. 


observed  in  the  cortex  and  at  the  base  of  the  skull ;  in 
the  superior  maxilla  and  the  scapula  ;  seldom  in  the 


long  bones. 


STATISTICS. 

Statistics  show  that  fractures  of  the  bones  of  the 
extremities,  including  those  of  the  clavicle,  represent 
three-fourths,  while  those  of  the  bones  of  the  trunk 
comprise  but  one-sixth,  and  those  of  the  skull  but  one- 
twenty-fifth,  of  all  fractures. 


SIGNS    OF    FRACTURES.  2  1 

Fractures  of  the  upper  extremities  are  twice  as  fre- 
quent as  those  of  the  lower.  Most  frequent  are  the 
fractures  of  the  forearm,  iS  per  cent.  ;  then  follow 
those  of  the  leer,  of  the  ribs,  and  of  the  clavicle,  i  z 
per  cent.  ;  hand,  1 1  per  cent. ;  humerus,  7  per  cent.  ; 
femur,  6  per  cent.  ;  foot,  2.6  per  cent.  ;  face,  2.4  per 
cent.  ;  skull,  1.4  per  cent.  ;  patella,  1.3  per  cent.  ;  scap- 
ula, spinal  column,  and  pelvis,  less  than  1  per  cent.  ; 
sternum,  o.  1  per  cent.  Most  fractures  occur  between 
the  thirtieth  and  fortieth  years.  Fractures  are  four 
and  a  half  times  more  frequent  in  men  than  in  women. 


SIGNS  OF  FRACTURES. 

The  symptoms  of  a  fracture  are  represented  by  a 
chain  of  mechanical  disturbances,  set  up  by  the  solu- 
tion of  the  continuity  of  the  bone.  The  most  impor- 
tant of  these  are  abnormal  mobility,  crepitus,  functional 
disability,  deformity,  ecchymosis,  and  pain. 

1.  Abnormal  mobility  is  the  most  characteristic 
sign  of  the  presence  of  a  fracture.  It  is  absent  in  the 
incomplete  variety  (fissures,  infractions,  etc.;  see  Figs. 
92,  137),  and  also  in  impacted  fractures — for  example, 
in  impacted  fracture  of  the  neck  of  the  femur.  (See 
Fig.  107.)  In  fractures  of  the  ribs  and  the  short  bones 
unnatural  mobility  is  also  often  looked  for  in  vain. 

2.  Crepitus  is  the  peculiar  sensation  felt  when  fric- 
tion is  caused  between  the  two  separated  bone-frag- 
ments. Crepitus  is,  of  course,  absent  when  there  is 
no  abnormal  mobility,  since  the  production  of  the 
characteristic  friction  presupposes  the  mobility  of  the 
fragments.      Consequently,  also,  there  is  no  crepitus  in 


2  2  FRACTURES    IN    GENERAL. 

fissures  and  infractions  (green-stick  fractures),  nor  in 
impacted  fractures.  Crepitus  is  also  absent  in  cases 
of  the  wide  separation  of  the  fragments,  whether  this 
be  caused  by  diastasis  (fracture  of  patella  or  ole- 
cranon), or  by  the  interposition  of  fascia  or  muscular 
tissue  between  the  displaced  fragments.  These  cir- 
cumstances will  prevent  mutual  contact  between  the 
ends  of  the  fragments.  In  other  cases  the  fragments 
overlap  each  other  to  such  an  extent  that  contact  be- 
tween the  broken  ends  is  impossible  (longitudinal  dis- 
placement;  compare  p.  iS),  or  sharp  and  displaced 
bone-fragments  are  driven  into  the  muscular  tissue,  so 
that  thus  an  interposition  of  soft  tissues  between  the 
broken  ends  of  the  bones  is  produced. 

3.  Functional  disability  is  seldom  absent.  Its 
extent  naturally  depends  upon  the  shape  and  kind  of 
the  bone  as  well  as  of  the  fracture.  This  is  shown  in 
the  cases  illustrated  by  figures  72  and  123.  There 
are  individuals  inured  to  pain  who  are  able  to  use 
their  arms  notwithstanding  the  fracture  of  both  radii, 
or  who  are  able  to  walk  a  short  distance  in  spite 
of  having  sustained  a  malleolar  fracture  ;  but  such 
occurrences  are  to  be  regarded  as  very  exceptional. 
Still,  from  a  legal  point  of  view  the  knowledge  of  such 
possibilities  is  of  the  utmost  importance. 

4.  Deformity  is  present  in  those  fractures  wherein 
more  or  less  displacement  of  the  fragments  has  taken 
place.  Consequently,  it  will  not  often  occur  in  cases 
of  fissure  or  in  infractions  ;  in  other  words,  in  fractures 
where  neither  abnormal  mobility  nor  crepitus  is  to  be 
found. 

Thus  it  can  be  seen  that  the  three  important  signs, 
abnormal  mobility,  crepitus,  and  deformity,  usually  go 


DIAGNOSIS.  23 

together.  It  must  be  added  that  wherever  deformity 
indicates  more  or  less  displacement,  shortening  of  the 
broken  bone  is  seldom  missed. 

5.  Ecchymosis  is  naturally  most  marked  in  direct 
fractures.  It  is  produced  by  the  laceration  of  small 
blood-vessels  and  of  the  medulla  of  the  bone.  If  the 
fracture  extends  into  the  joint,  there  is  always  an  extra- 
vasation of  blood  within  the  joint  (hemarthrosis). 
Ecchymosis  is  generally  more  marked  a  few  days  after 
the  injury  is  sustained. 

6.  Localized  pain  is  a  constant  symptom  of  frac- 
ture. It  is  increased  by  pressure  and  by  every  active 
or  passive  effort  that  displaces  the  fragments. 


DIAGNOSIS. 

In  most  cases  the  presence  of  a  fracture  can  be  rec- 
ognized even  by  simple  inspection.  (Compare  Fig. 
33.)  If  the  trifolium — abnormal  mobility,  crepitus,  and 
displacement — is  present,  the  proof  of  fracture  is  estab- 
lished beyond  doubt.  The  value  of  inspection  should 
not  be  underestimated.  In  fact,  the  part  should  be  in- 
spected very  thoroughly  before  palpation  is  resorted 
to.  The  custom  of  handling  an  injured  organ  by 
pressing,  turning,  and  squeezing  before  it  is  carefully 
looked  at  can  not  be  condemned  too  strongly.  It  pays 
very  well  to  inspect  the  injured  area  for  some  length 
of  time,  and  to  compare  it  with  the  normal  outlines  of 
the  opposite  side,  until  there  is  a  clear  idea  of  the  con- 
dition of  things  in  the  examiner's  mind. 

But  if  there  be  an  infraction  or  a  fissure  or  an  im- 
pacted fracture,  or  in   cases  where  one  of  two  parallel 


24  FRACTURES    IN    GENERAL. 

bones  is  fractured  (forearm,  for  instance;  see  Fig.  60), 
or  if  the  break  has  occurred  near  a  joint,  or  if  there  be 
extensive  inflammation,  the  diagnosis  may  be  very  dif- 
ficult, and  the  injury  may  be  mistaken  for  a  contusion 
or  a  distortion,  or  even  a  dislocation. 

As  to  dislocation,  it  should  be  borne  in  mind  that  this 
injury  does  not  lead  to  any  abnormal  mobility  nor  any 
shortening  of  the  bone-shaft. 

In  contusions  the  absence  of  abnormal  mobility,  crepi- 
tus, displacement,  and  shortening  will  be  observed.  It 
is  obvious  that  these  differential  points  are  mainly  to 
be  elicited  by  manual  examination.  This  process  being 
always  productive  of  more  or  less  pain,  it  should  be 
performed  with  a  great  deal  of  care.  While  it  is  often 
possible  to  diagnosticate  the  presence  of  a  fracture  by 
means  of  careful  palpation,  conclusions  as  to  its  direc- 
tion and  as  to  the  size  of  the  broken  fragments  could 
seldom  be  drawn  in  the  pre-R6ntgenian  era  unless  the 
patient  was  anesthetized.  If  there  be  abnormal  mobility, 
manual  examination  will  naturally  yield  crepitus  also. 

Whether  or  not  there  is  shortening  of  the  limb  can 
be  ascertained  by  measurement.  It  must  be  borne  in 
mind,  however,  that  the  points  from  which  measuring 
with  a  tape  are  begun  fail  to  show  mathematic  exact- 
ness and  regularity.  They  are  represented  by  round- 
shaped  bony  protuberances,  like  the  anterior  superior 
spine  of  the  ilium,  the  major  trochanter  or  the  external 
condyle  of  the  femur,  the  external  malleolus  of  the 
fibula,  the  styloid  process  of  the  radius,  and  the  olec- 
ranon and  acromion  in  the  upper  extremity. 

This  variation  in  position  of  the  points  of  measure- 
ment explains  why  an  error  to  the  extent  of  a  whole 
inch  can  easily  be  made.     With  the  employment  of  all 


DIAGNOSIS.  25 

these  means,  fractures  have  often  failed  to  be  correctly 
diagnosticated  even  by  the  greatest  surgical  masters 
of  all  centuries.  The  courts  can  show  endless  his- 
tories of  grave  errors  committed  to  the  detriment  of 
poor  patients  and  not  the  less  of  poor  practitioners. 
But  the  discovery  of  Wilhelm  Conrad  Rontgen  has 
come  to  do  away  with  all  this.  At  present  there  are 
no  fractures  the  character  of  which  can  not  be  estab- 
lished beyond  a  doubt.  But  much  more  has  been 
shown  to  us  by  these  rays.  A  glance  at  the  fluoro- 
scope  not  only  gives  one  an  idea  of  the  special  type 
of  the  fracture,  but  the  situation,  shape,  and  the 
number  of  the  fragments  and  their  correlation  can  be 
clearly  ascertained.  The  photographic  plate  fixes  the 
details  of  the  fracture  exactly,  and  permits  of  the 
thorough  study  of  the  various  features  of  the  fracture 
type.  Its  comparison  with  the  normal  skeleton  makes 
the  abnormalities  evident  at  once,  so  the  use  of 
anesthetics,  which  in  many  cases  are  not  at  all  advan- 
tageous for  the  patient's  physical  condition,  is  no 
longer  required  in  diagnosis.  It  is  clearly  seen  that 
the  advent  of  the  Rontgen  rays  has  accomplished  no 
less  than  a  revolution  in  the  understanding  of  frac- 
tures. On  account  of  their  special  importance,  the 
diagnostic  use  of  skiagraphy  is  considered  in  a  sepa- 
rate section. 


2  6  FRACTURES    IN    GENERAL. 

THE    PROCESS    OF    REPAIR    AND    THE 
FORMATION  OF  CALLUS. 

Repair  of  simple  subcutaneous  fractures  generally 
takes  place  without  any  constitutional  disturbance. 
The  course  being  an  aseptic  one,  fever,  as  a  rule,  is 
absent.  When  there  is  much  extravasation,  infiltra- 
tion, or  destruction  of  tissue,  the  lively  absorption  of 
blood-ferment  may  cause  slight  and  transient  elevation 
of  temperature  (up  to  101.50  F.)  {aseptic  absorption- 
fever). 

Microscopic  examination  of  the  urine  shows,  with 
few  exceptions,  for  the  first  four  or  five  days  following 
the  injury,  cylindric  elements,  brownish  clots,  and  the 
relics  of  shrunken  blood-corpuscles.  Traces  of  albu- 
min are  also  often  found  in  the  urine.  Fat  is  absorbed 
from  the  shattered  medulla  of  the  bone  by  the  lymph- 
vessels,  and  gains  access  thereby  to  the  blood-circula- 
tion, from  which  it  is  generally  excreted  slowly  without 
causing  any  disturbance.  In  the  urine  its  presence  is 
also  not  infrequently  demonstrated.  In  cases  of  ex- 
tensive shattering,  however,  or  in  multiple  fractures, 
an  abundance  of  fat  accumulated  in  the  circulation  is 
sometimes  caused,  which  may  lead  to  fat  embolism. 
In  this  extremely  grave  condition,  which  is  nearly 
always  fatal,  there  is  in  the  capillaries  a  conflux  of  fat- 
globules,  which  causes  the  obstruction  of  numerous 
capillary  channels  by  cylindric  masses  of  fat.  This 
occurs  especially  in  the  lungs.  The  blood-vessels  that 
are  incarcerated  between  these  masses  are  compelled 
by  pressure  to  give  their  serum  away  to  the  lung 
tissue,  so  that  edema  of  the  lungs  is  produced. 

The  symptoms  of  this  condition  are  those  of  shock  ; 


FRACTURE-REPAIR    AND    CALLUS-FORMATION.  2J 

they  never  appear  as  a  primary  shock  occurring- imme- 
diately after  the  injury  was  sustained,  but  manifest 
themselves,  as  a  rule,  on  the  third,  or  sometimes  even 
on  the  fourth  or  fifth,  day.  Owing  to  the  edematous 
condition  of  the  lungs,  dyspnea,  combined  with  cardiac 
irregularity,  naturally  is  a  prominent  symptom. 

The  swelling  of  the  soft  tissues  in  the  immediate 
vicinity  of  the  fracture  is  caused  by  extravasation  and 
edema,  the  latter  being  produced  by  a  slight  degree 
of  inflammation.  The  swelling  generally  disappears 
by  absorption  in  the  course  of  the  first  week.  The 
integument,  which  had  been  overextended  by  the  swell- 
ing, becomes  flabby,  and  at  the  same  time  loses  its 
original  bluish-black  discoloration  and  shows  the  char- 
acteristic rainbow  tints. 

Formation  of  Callus. — Hand  in  hand  with  the 
absorption  process  goes  the  formation  of  a  new  bone- 
tissue,  called  callus,  which  originates  between  and 
around  the  broken  ends  and  gradually  fills  up  the 
separation  line,  thus  restoring  the  continuity  of  the 
broken  bone. 

,  Most  of  the  callus  is  formed  from  the  inner  strata  of 
the  periosteum,  while  the  medullary  tissue  furnishes 
the  rest.  The  first  indication  of  the  healing  process  is 
the  occurrence  of  a  periosteal  swelling  [periostitis 
ossificans),  which  is  caused  by  the  proliferation 
of  the  osteoblastic  cells,  between  which  lime-salts 
are  deposited.  (Fig.  3.)  Lacerated  portions  of  the 
periosteum  are  scattered  around  the  fracture  area 
and  form  another  starting-point  for  peripheral  growth. 
The  processes  of  cell-proliferation  and  calcification  of 
the  young  tissue  begins  simultaneously  from  the 
medullary  canal  and  Haversian   channels.     Afterward 


Osteoblasts. 

Newly  formed  bone. 


Old  bone. 


Fig.  3. — Osteoblasts  on  old  bone. 


Fig,  4. — Longitudinal  section  through  a  fractured  fibula  in  a  young  adult 
(two  weeks  after'  the  injury):  a,  Fatty  medulla;  b,  myelogenous  bone-tra- 
beculte;  c,  corticalis ;  (//myelogenous  trabecule,  consisting  of  osteoblasts  and 
osteoid  tissue  ;  e,  connective  tissue  between  the  fragments  ;  /,  newly  formed  car- 
tilage ;  g,  fragment  separated  from  the  fibula;  h,  osteoblasts;  i,  periosteal  osteo- 
phytes. 

2S 


FRACTURE-REPAIR    AXD    CALLUS-FORMATION.  29 

the  periosteal  and  medullary  calluses  join  within  the 
separation  line,  so  that  the  bone-ends  are  surrounded 
exteriorly  by  a  broad  ring,  while  interiorly,  or  within 
the  medullary  canal,  they  are  fastened  by  a  plug  of 
young  bone-tissue.  (Fig.  4.)  A  conception  of  the 
progress  of  this  formation  can  be  gained  by  palpation, 
which  reveals  a  spindle-shaped  thickening  of  a  slightly 
cartilaginous  character  around  the  line  of  bone  separa- 
tion. (Compare  Fig.  1 13.)  A  few  weeks  after  the  in- 
jury, when  the  formation  of  the  external  ring  (periosteal 
callus)  and  of  the  internal  plug  (medullary  callus)  is  com- 
pleted, the  periosteal  swelling  subsides  also,  the  callus 
becomes  solid,  and  mobility  ceases  to  be  observable. 

The  length  of  time  necessary  for  perfect  consolidation 
varies  between  two  and  twelve  weeks,  according  to  the 
size  of  the  bones.  From  the  statistics  of  E.  Gurlt  it  is 
learned  that  perfect  consolidation  of  complete  subcu- 
taneous fractures  requires  for — 

Metacarpal   or  metatarsal    bones,   as 

well  as  ribs 3  weeks. 

Clavicle 4  " 

Forearm 5  " 

Humerus  and  fibula 6  " 

Surgical  necks  of  humerus,  and  tibia  7  " 

Tibia  and  fibula  together 8  " 

Femur 10  " 

Neck  of  femur 12  " 

For  some  time  after  this  complete  consolidation  has 
taken  place  the  anatomic  condition  of  the  callus  by  no 
means  remains  unchanged.  Years  may  elapse  before 
the  original  callus-tissue  is  completely  absorbed  and 
the  regular  bone-system  with  the  normal  medullary 
canal  is  reestablished,  as  is  easily  proved  by  the 
Rontgen  rays.     According  to   the  degree  of  displace- 


30  FRACTURES    IN    GENERAL. 

ment  there  is  abundant  callus  proliferation,  so  that 
sometimes  enormous  masses  are  thrown  out,  and  may 
be  mistaken  for  regular  osteomas.  In  children,  in 
whom  there  is  frequently  but  little  periosteal  lacera- 
tion, there  is  sometimes  so  little  callus  formation  that 
even  the  Rontgen  rays  disclose  but  a  very  thin  line 
of  separation.  In  such  cases  the  evidence  of  a  frac- 
ture may  not  be  proved  by  the  rays  two  months  after 
the  injury  was  sustained.      (Fig.  137.) 

Since  aseptic  treatment  has  brought  the  mortality  of 
compound  fracture  from  45  per  cent,  down  to  nearly 
nil,  the  consolidation  of  fragments  in  this  condition, 
formerly  so  much  dreaded,  generally  takes  place  with- 
out inflammatory  reaction,  or  with  very  little. 

Even  in  pre-antiseptic  times  such  consolidation  was 
occasionally  observed  in  one  class  of  compound  frac- 
tures :  namely,  gunshot  wounds. 

In  compound  fractures  necrosis  of  one  or  both 
bone-ends  sometimes  occurs.  This  is  caused  by  the 
detachment  of  periosteum,  so  that  the  vascular  supply 
is  diminished.  A  line  of  demarcation  usually  forms 
between  the  normal  and  the  necrosed  tissue  ;  and  in  be- 
tween two  and  six  months  after  this  the  necrotic  bone 
exfoliates.  Meanwhile  the  ossifying  inflammation  of 
the  periosteum  creates  abundant  bone-substance,  so 
that  enough  material  for  thorough  consolidation  is 
furnished. 

Sometimes  callus  formation  is  late.  Among  all  frac- 
tures, that  of  the  upper  third  of  the  humerus  shows  the 
greatest  tendency  for  late  union.  The  cause  for  this 
condition  can  but  seldom  be  elicited.  Syphilis,  scurvy, 
rickets,  malignant  bone-disease,  and  paralysis  are  gen- 
erally held  responsible  for  it. 


DISTURBANCES    IN    THE    PROCESS    OF    REPAIR.  3 1 

DISTURBANCES    IN    THE    PROCESS    OF 

REPAIR. 

One  of  the  most  distressing"  disturbances  in  the 
healing  process  of  fractured  bones  is  the  failure  of  the 
occurrence  of  bony  union  between  the  broken  ends, 
the  consequence  of  which  is  the  formation  of  a  new 
false  joint  (pseudarthrosis).  Pseudarthrosis  is  either 
called  fibrous,  in  which  case  the  only  junction  between 
the  fragments  consists  of  fibrous  tissue,  or  real,  when 
there  is  the  formation  of  a  true  joint-capsule,  the  latter 
condition  being  extremely  rare.  (Fig.  135.)  Excep- 
tionally, however,  a  synovial  membrane  and  synovia 
are  formed.  It  is  self-evident  that  in  either  event, 
whether  there  follows  either  a  fibrous  or  a  true  pseud- 
arthrosis, the  bone-ends  remain  movable. 

The  causes  of  false  mobility  may  be  either  local  or 
constitittiojial.  Late  necrosis  of  the  callus,  caused  by 
inflammation  and  suppurative  infection  from  a  focus 
(furuncle,  tonsillitis),  even  in  simple  subcutaneous 
fractures,  and  especially  in  the  extensive  crushing  of 
the  broken  area,  so  often  produced  by  compound  frac- 
tures, favors  its  formation.  Scant  callus  formation, 
which,  as  before  stated,  often  delays  union,  may  also 
be  responsible  for  pseudarthrosis. 

Interposition  of  soft  tissues  (muscle,  fascia,  and  ten- 
don) produces  pseudarthrosis  with  absolute  certainty. 
This  intervention  is  most  frequently  observed  in  the 
humerus  and  the  femur,  a  fact  which  is  explained  by 
the  great  tendency  to  extensive  displacement  mani- 
fested in  these  long  bones.  In  these  cases  thick 
masses  of  surrounding  muscle  are  easily  pushed  be- 
tween the  fragments.     As  before  mentioned,  overrid- 


32  FRACTURES    IN    GENERAL. 

ing  of  the  fragments  may  produce  pseudarthrosis, 
even  if  there  be  profuse  callus  formation. 

The  constitutional  causes  favoring  non-union  are  the 
same  as  those  that  cause  late  union.  Pseudarthrosis 
takes  place  in  about   i  in  400  fracture  cases. 

Gangrene  may  be  the  result  of  a  mechanical  or  of  a 
traumatic  cause.  The  application  of  too  tight  a  splint 
is  a  well-known  and  most  deplorable  mechanical  cause 
of  gangrene.  Extensive  pulping  or  laceration  of  soft 
tissues  or  the  rupture  of  a  large  blood-vessel,  often 
caused  by  a  crush  or  by  sharp  bone- fragments,  may 
lead  to  extensive  blood-extravasation,  which  is  liable  to 
result  in  gangrene.  It  hardly  needs  to  be  stated  that 
these  lesions  are  of  a  severe  character.  The  anterior 
and  posterior  tibial  arteries  are  those  most  frequently 
observed  to  become  ruptured  in  this  manner. 

The  same  causes  may  sometimes  produce  aneu- 
rysm. 

A  mechanical  insult  to  a  nerve  situated  at  the  point 
of  a  fracture  may  also  lead  to  a  series  of  complications. 
There  may  be  a  direct  injury  done  to  a  nerve,  as,  for 
instance,  to  the  radial  or  peroneal  nerve  ;  or  a  perfora- 
tion by  a  bone-splinter  (interposition  of  the  nerve)  of 
the  nerve  that  rests  directly  upon  the  bone.  (Fig.  66.) 
In  other  cases  pressure  conveyed  to  the  nerve  by 
exuberant  callus  proliferation  (Fig.  67)  produces  loss 
of  sensation  or  motion,  or  of  both.  If  the  paralytic 
symptoms  appear  slowly  and  gradually,  it  may  be 
regarded  as  an  absolute  pathognomonic  sign  that  the 
nerve-pressure  is  clue  to  exuberant  callus  formation. 

Embolism  and  thrombosis  are  very  rare  occur- 
rences in  subcutaneous  fractures.  These  conditions 
are  mostly  observed  in   fractures  of  the  bones  of  the 


lower  extremity.  Their  cause  is  the  formation  of  a 
blood-clot,  induced  by  the  trauma  of  a  vein.  From  the 
clot  obstructing  the  vein  (thrombosis)  an  embolus  may 
originate,  which,  after  being  torn  away,  may  reach  the 
pulmonary  artery  ;  and  sudden  death  may  follow  the 
plugging  of  this  artery.  The  signs  that  foretell  this 
fatal  occurrence  are  sudden  suffocation,  cyanosis,  dysp- 
nea, and  an  imperceptible  pulse.  There  are,  however, 
a  few  cases  on  record  in  which,  in  spite  of  the  marked 
development  of  the  clinical  symptoms  of  this  grave  con- 
dition, recovery  has  taken  place. 

Ankylosis  (from  ayxokoq,  "angular,  crooked")  may 
be  bony  or  fibrous.  Bony  ankylosis  maybe  originated 
by  a  direct  fracture  into  a  joint,  followed  by  an  inflam- 
matory process,  which  in  the  course  of  time  unites  the 
bone-fragments  among  themselves  within  the  joint. 
(See  Fig.  1 18.) 

Fibrous  ankylosis  may  be  caused  by  an  inflammatory 
process  in  the  joint.  This  may  have  been  produced 
by  some  condition  such  as  a  profuse  hemorrhage  into 
the  joint,  leading  to  synovitis  or  arthritis,  from  which 
adhesions  within  the  joint  may  follow.  Hematoma,  if 
not  absorbed,  may  also  lead  to  serous  or  purulent  teno- 
synovitis. If  plastic  inflammation  is  set  up  in  the  sheath 
of  a  tendon  in  the  vicinity  of  a  joint,  stiffness  of  the 
joint  may  result  (tenogenous  ankylosis).  This  is 
especially  observed  in  non-reduced  fractures  of  the 
lower  end  of  the   radius. 

Prolonged  immobilization  also  sometimes  pro- 
duces mild  forms  of  fibrous  ankylosis. 

Atrophy  is  nearly  always  caused  by  prolonged  inac- 
tivity of  the  muscles.  But,  in  the  course  of  time,  it  will 
affect  not  only  the  muscles,  but  also  the  tendons.     Just 


34  FRACTURES    IN    GENERAL. 

as  a  sword  becomes  so  rusty  in  its  scabbard  that  it  can 
not  be  drawn,  so  may  a  tendon  become  adherent  to  its 
sheath,  if  it  be  not  frequently  moved  to  and  fro. 
Motion  induces  the  secretion  of  the  synovia  in  the  ten- 
don-sheath and  thereby  keeps  up  the  possibility  of  the 
smooth  gliding  of  the  tendon  therein. 

Delirium  tremens  is  a  not  infrequent  and  often  a 
fatal  complication.  It  is  characterized  by  the  violent 
inclinations  of  the  patient,  the  presence  of  delusions, 
and  the  entire  absence  of  fever.  An  alcoholic  history 
will  but  seldom  be  absent. 

Pneumonia  is  provoked  by  prolonged  dorsal  de- 
cubitus (hypostatic),  and  is  especially  apt  to  occur  in 
alcoholics  and  old  patients. 

In  summing  up  it  can  readily  be  seen  that  if  the 
causes  of  the  disturbances  in  the  process  of  repair  be 
analyzed  thoroughly,  it  will  be  found  that,  except  in  a 
few  cases,  the  ill  results  specified  can  be  avoided  by 
carefully  controlling  the  course  of  a  fracture.  Since 
asepsis  began  its  triumphant  march  the  evil  conse- 
quences of  even  compound  fractures  have  been 
reduced  to  a  minimum.  (Compare  p.  51.)  Life  is 
generally  only  endangered  nowadays  when  organs  of 
vital  importance,  such  as  the  brain,  spine,  lungs,  or 
pelvic  viscera,  are  injured. 


TREATMENT. 

The  laws  that  govern  the  treatment  of  fractures  are 
determined  by  a  correct  diagnosis.  In  fact,  the  princi- 
ples of  treatment  are  reduced  to  a  few  points  of  simple 
common  sense  as  soon  as  there  is  a  complete  and  cor- 
rect diagnosis. 


TREATMENT.  35 

Simple  subcutaneous  fractures  showing  but  little  or 
no  displacement  often  heal  without  any,  or  in  spite  of 
any,  treatment,  as  the  long  sin-register  of  quackery 
demonstrates;  and  the  number  of  fractures  not  recog- 
nized as  such  during  treatment  is  legion. 

The  first  object  of  a  rational  therapy  is  the  consoli- 
dation of  the  fractured  ends  without  any  displacement 
and  without  injuring  the  adjacent  tissues  or  the  func- 
tion of  the  limb.  It  is  evident  that  if  there  is  no  dis- 
placement,  no  replacement  (or,  better  said,  no  reposi- 
tion) will  be  necessary.  All  that  is  required  then  is 
to  protect  the  injured  limb  in  its  normal  position. 
This  is  done  by  proper  immobilization. 

In  the  great  majority  of  cases,  however,  more  or  less 
displacement  of  fragments  follows  the  fracture.  In 
such  an  event,  of  course,  the  displaced  fragments  must 
be  reduced  to  their  normal  position.  After  exact  reposi- 
tion has  been  attained,  proper  fixation  in  the  normal 
position  is  in  order. 

These  doctrines  are  so  simple  that  it  seems  almost 
unnecessary  to  repeat  them.  And  yet  they  are  vio- 
lated frequently.  The  functional  impairment  following 
some  fractures,  especially  the  formation  of  adhesions 
in  the  vicinity  of  joints,  has  led  a  number  of  surgeons 
to  enunciate  this  dogma  :  "  The  most  important  part 
in  the  treatment  of  fracture  is  the  treatment  of  the 
soft  tissues."  They  claim,  in  other  words,  that  because 
the  function  of  the  soft  tissues — for  instance,  of  the 
tendons — is  impaired  after  a  non-reduced  fracture,  the 
soft  tissues  should  have  received  more  attention,  in- 
stead of  the  displaced  fragment  having  simply  been 
reduced  to  where  it  belongs.  Nothing,  in  fact,  is  more 
contrary  to  common  sense  than  this  dangerous  maxim, 


3 


6  FRACTURES    IN    GENERAL. 


which  is  based  upon  correct  observation,  but  incorrect 
interpretation.  It  should  always  be  considered  that 
the  relations  of  the  soft  tissues  to  the  bones  are  like 
that  of  the  clinging-  vine  to  the  sturdy  oak. 

Galen  says  that  the  bones  give  the  human  body 
form,  erectness,  and  firmness.  It  is  evident  that  an 
injury  of  the  bones  impairs  these  three  fundamental 
factors.  The  most  important  step  toward  repair  must 
thus  be  taken  in  the  foundations  rather  than  in  the 
superimposed  structure. 

If  there  is  displacement  of  the  bone-fragments,  un- 
due pressure  must  necessarily  be  made  upon  the  soft 
tissues  ;  non-reduction  means  persistence  of  pressure,  the 
fatal  consequences  of  which  are  well  known.  Reduction 
means  the  relief  of  pressure.  Of  course,  the  act  of  in- 
jury can  not  be  undone  by  the  mere  cessation  of  pres- 
sure ;  but  the  influence  of  the  injury  on  the  soft  tissues — 
the  influence  of  the  pressure,  in  fact — lasts  only  a  short 
time  and  is  insignificant  after  early  reduction  ;  there 
is  then  but  little  inflammation,  and  consequently  little 
exudation,  and  therefore  repair  is  easy.  This  means 
that  the  premises  of  adhesion-formation  are  wanting. 
And  clinical  observation  shows  that  if  there  was  per- 
fect reposition,  the  joints  as  well  as  the  sheaths  of  the 
tendons  are  found  free,  provided  the  immobilization 
has  not  lasted  for  an  extraordinary  length  of  time. 

To  accomplish  exact  reposition,  it  is  desirable  to 
have  the  assistance  of  one  or  two  persons,  who  should 
make  extensive  counterextension  while  the  surgeon 
replaces  the  displaced  fragments.  In  fractures  of  the 
bones  of  the  upper  extremity  assistance  can  be  dis- 
pensed with,  but  in  those  of  the  lower  extremity 
proper  reposition  is  hardly  possible  without  the  assist- 


TREATMENT.  $*] 

ance  of  at  least  one  person.  If  the  exact  situation  of 
the  fragments  has  been  ascertained  (and  this  can 
always  be  done),  the  surgeon  should  know  at  once 
how  to  replace  them  to  their  former — that  is,  to  their 
normal — position.  This  is  done  by  making  manipu- 
lations either  in  the  way  of  pressing  sideward  and 
turning  one  of  the  fragments,  or  by  putting  the  limb 
into  a  proper  angle,  and  thus  correcting  the  abnormal 
direction. 

Whenever  the  fragments  can  be  seized  by  the  sur- 
geon's fingers  reduction  will  be  found  easy ;  but  if 
their  manipulation  is  difficult,  anesthesia  is  to  be  em- 
ployed. If  the  surgeon  is  undecided  as  to  whether 
he  should  administer  an  anesthetic,  he  should  give  the 
benefit  of  the  doubt  to  the  anesthesia.  Reduction  is 
especially  difficult  where  there  is  extensive  displace- 
ment of  the  fragments,  or  if  their  sharp  edges  have 
pierced  the  sott  tissues,  or  if  muscular  tissue  inter- 
venes, or  in  the  rare  event  of  simultaneous  dislocation. 
But  all  these  conditions  can  easily  be  ascertained  by 
the  Rontgen  rays,  and  under  their  guidance  reposition 
will  always  be  successful. 

If  a  fracture  has  been  sustained  in  the  street,  some 
kind  of  improvised  splint  should  be  applied,  and  no  re- 
duction should  be  tried  before  the  patient  has  reached 
his  home  ;  but  as  soon  as  he  has  arrived  there,  reposi- 
tion should  be  undertaken  at  once,  since  the  whole 
course  of  recovery  might  be  jeopardized  by  delaying 
this  most  important  procedure. 

If  the  upper  extremity  is  concerned,  the  surgeon 
may  seize  each  fragment  with  one  hand,  and  by  pull- 
ing and  counterpulling  the  fragments  are  slowly  put 
into  their  normal  position. 


38  FRACTURES    IN    GENERAL. 

In  fractures  of  the  bones  of  the  lower  extremity  the 
patient  should  be  placed  upon  a  firm  bed.  Clothing, 
shoes,  etc.,  in  the  vicinity  of  the  fracture  should  be  cut 
off,  to  avoid  any  unnecessary  manipulation  of  the 
broken  area.  The  limb  must  be  carefully  lifted,  con- 
stant extension  being  exercised  at  the  same  time. 

The  pelvis  must  be  immobilized,  which  is  best 
accomplished  by  one  assistant  putting  his  hands  on 
the  crests  of  the  ilia  and  pressing  the  pelvis  down 
upon  a  tight  underlayer  ;  or  the  pelvis  may  be  drawn 
upward  by  slinging  a  long  towel  around  the  perineum. 
The  surgeon  should  now  seize  the  patient's  foot  on 
the  heel  with  his  left  and  on  the  metatarsus  with  his 
right  hand,  while  he  pulls.  When  he  has  lifted  the 
foot  to  the  horizontal  position,  the  fragments  are  care- 
fully turned  to  and  fro,  according  to  the  direction  of 
the  displacement,  until  the  tip  of  the  foot,  the  interior 
margin  of  the  patella,  and  the  anterior  superior  spine 
of  the  os  ilii  are  in  a  straight  line. 

If  two  assistants  can  be  obtained,  they  can  make 
extensive  counterextension,  and  the  surgeon  may  then 
reduce  the  displaced  fragments  by  simply  pushing 
them  into  their  proper  positions. 

If  extravasation  be  exceptionally  profuse,  punctur- 
ing or  massage  treatment  should  be  employed  until  it 
becomes  possible  to  grasp  and  reduce  the  displaced 
fragments.  (As  to  the  technic  of  puncture,  see  the 
section  on  the  Treatment  of  Patellar  Fracture.) 

After  reposition  is  accomplished,  immobilization  of 
the  reduced  fragments  must  be  secured  in  order  to 
retain  them  in  their  proper  place.  For  this  purpose 
the  broken  bone-ends  as  well  as  the  adjoining  joints 
must    be   surrounded   with   suitable   apparatus  in   the 


TREATMENT.  39 

shape  of  splints  and  bandages.  If  nothing  else  be  at 
hand,  shutters,  pillows,  or  similar  improvised  contriv- 
ances may  be  utilized. 

On  the  battle-field  bayonets,  sabers  and  their  scab- 
bards, muskets,  etc.,  may  serve  as  temporary  splints. 

The  thorax  may  act  as  a  splint  for  a  broken  arm,  if 
necessary,  the  arm  being  fixed  upon  it.  In  like  man- 
ner a  broken  leg  may  be  fixed  upon  the  sound  one. 

Fixed  Dressings. — As  soon  as  reposition  has  been 
perfected,  fixed  dressings  (splints,  plaster-of- Paris,  etc.) 
should  be  employed  for  the  purpose  of  retaining  the 
fragments  in  their  proper  positions.  In  case  complete 
reduction  can  not  be  accomplished  at  once,  extension 
dressings  are  preferable. 

All  fixed  dressings  require  an  underlayer,  consisting 
of  cotton,  flannel,  or  muslin,  in  order  to  avoid  pres- 
sure upon  the  swollen  area  and  at  the  same  time  to 
prevent  the  hairs  of  the  skin  from  adhering  to  the 
dressing. 

It  is  a  matter  of  skill  and  experience  to  apply  a 
dressing  tight  enough  to  render  shifting  of  the  frag- 
ments impossible,  and,  on  the  other  hand,  to  apply  it 
so  smoothly  that  there  is  no  pressure.  Gangrene  of 
that  portion  of  the  skin  resting  directly  upon  a  bone- 
protuberance  is  easily  produced  even  by  a  moderate 
amount  of  pressure.  It  is  wise,  therefore,  to  pad  such 
dangerous  areas  profusely. 

Venous  stasis  and  edema,  finally  leading  to  necrosis, 
may  be  caused  by  too  tight  an  application  of  a  simple 
bandage.  To  avoid  such  possibilities  it  is  advisable, 
in  all  fixed  dressings,  to  leave  fingers  and  toes  always 
uncovered,  so  as  to  have  permanent  control. 

No  dressing  accomplishes  the  purpose  of  retaining 


4-0  FRACTURES    IN    GENERAL. 

the  fragments  better  than  pi aster-of- Paris,  since  it 
adapts  itself  to  the  contours  of  the  body  in  an  admir- 
able manner,  and  surrounds  it  at  the  same  time  like  a 
coat  of  mail.  The  best  quality  is  not  too  good  for 
use  in  a  surgical  dressing.  The  extra-calcined  variety 
(CaS042H20),  such  as  is  used  by  dentists,  is  consid- 
ered the  best.  Good  plaster  must  set  quickly  and 
firmly  ;  in  fact,  it  must  become  hard  in  about  a  minute 
after  the  dressing  is  complete. 

In  making  plaster-of-Paris  bandages  the  following 
points  should  be  observed :  The  plaster-of-Paris  is 
dusted  over  a  crinoline  bandage  about  five  yards  long 
and  from  two  to  four  inches  wide.  The  bandage  is 
best  laid  upon  a  table  and  the  plaster  rubbed  well 
into  its  meshes,  where  it  is  evenly  distributed.  After 
thorough  impregnation  it  is  rolled  up  loosely  and  stored 
in  an  air-tight  can  until  needed. 

When  used,  the  plaster  bandage  is  immersed  in  luke- 
warm water  until  bubbles  cease  to  come  up,  which  fact 
announces  its  being  thoroughly  soaked.  Then  the 
bandage  is  squeezed  out  well  and  evenly  and  is  firmly 
applied.  Reverses  must  be  avoided.  To  give  the 
dressing  a  nice  appearance,  some  dry  plaster  may  be 
moistened  well  with  water  until  the  consistence  of 
thick  cream  is  obtained.  This  paste  is  then  evenly 
rubbed  over  the  surface  of  the  dressing. 

If  there  are  small  wounds  present  that  require  an 
aseptic  dressing,  a  small  opening  (fenestra)  should  be 
made  over  them.  If  they  are  covered  with  a  small 
glass  or  bottle  or  ointment-pot  while  the  bandages  are 
being  applied,  these  points  can  easily  be  kept  open. 
(Fig.  5.)  The  fenestral  margins  are  best  surrounded  by 
absorbent  cotton,  which  may  be  fastened  to  the  integu- 


TREATMENT. 


41 


ment  by  collodion.  At  the  knees,  the  groin,  etc.,  it  is 
necessary  to  strengthen  the  fenestral  margins  by  laying 
small  wooden  splints  so  as  to  prevent  breakage  of  the 
dressing. 

To  preserve  the  plaster  dressing  against  moisture  (a 
femoral  dressing  in  a  child  will  surely  be  destroyed  if 


Fig.   5.— Fenestrated  plaster-of-Paris  dressing  (for. wound-treatment). 


moistened  with  urine),  it  should  be  painted  with  copal 
varnish.      (See  Fig.  115.) 

The  taking-off  of  a  plaster  dressing  is  generally  more 
troublesome  than  its  application.  The  best  instrument 
for  the  purpose  is  a  circular  saw  provided  with  a  beak. 
If  this  instrument  is  not  at  hand,  a  grooved  line,  into 
which  salt  water  or,  preferably,  vinegar  is  poured,  is 
scratched  into  the  plaster.  This  will  facilitate  cutting 
through  the  plaster  layer  alongside  this  marked  line. 


42  FRACTURES    IN    GENERAL. 

During  the  last  few  years — thanks  to  the  impetus  of 
Hessing,  the  ingenious  mechanician — the  application 
of  plaster  dressings,  especially  to  the  lower  extremity, 
immediately  after  the  fracture  is  sustained  has  been 
highly  recommended  by  F.  Krause,  Korsch,  Albers, 
and  others.  (Fig.  6.)  In  many  instances  the  patients 
have  been  permitted  to  go  about  after  an  interval  of  a 
day  or  two. 

Ambulatory  Dressing. — The  advantages  of  this  am- 
bulatory dressing  are  obvious.  Atrophy  of  the  mus- 
cles is  surely  avoided,  as  their  functions  are  not  inter- 
rupted. Late  union  or  non-union  does  not  occur,  if  this 
method  is  employed,  since  callus  formation  is  abundant. 
Hypostatic  pneumonia,  so  dangerous  in  aged  people,  is 
absolutely  excluded.  There  is  also  much  less  tendency 
to  delirium  tremens.  It  hardly  needs  to  be  mentioned 
that  this  form  of  treatment  adds  considerably  to  the 
patient's  comfort. 

In  supramalleolar  fracture,  or  that  of  the  head  of  the 
tibia  and  the  femoral  condyles,  and  in  fractures  of  the 
femur,  the  pelvis  may  serve  as  a  point  of  support.  The 
sole  portion  of  the  dressing  is  made  especially  strong, 
to  permit  of  stepping  upon  it.  At  first  the  patients  are 
allowed  to  move  only  in  a  go-cart. 

But  these  advantages  are  fairly  offset  by  the  im- 
mense difficulty  in  keeping  the  treatment  under  perma- 
nent control  in  practice.  The  technic  of  applying  such 
dressings  is  complicated,  and  therefore  is  dangerous  in 
the  hands  of  the  inexperienced.  In  hospital  practice, 
where  continuous  control  is  possible,  the  adoption  of  this 
method  in  many  instances  proves  to  be  of  great  value. 

So,  while  this  treatment  is  undoubtedly  advisable  in 
cases    in    which    the    dressing   can    be    removed    any 


TREATMENT. 


43 


moment,  in  case  ischemic  symptoms  should  manifest 
themselves,  it  should  not  be  recommended  for  adop- 
tion in  general  practice.  Proper  individualization, 
based    on    sound   judgment    and    experience,    should 


Fig.  6. — Ambulatory  dressing. 


fix  the  limits  to  its  applicability.  Here,  as  in  many 
other  instances,  the  golden  mean  should  be  chosen. 
The  writer  has  often  found  it  useful  to  permit  his 
patients  to  walk   about   as   soon   as   the   swelling  had 


44  FRACTURES    IN    GENERAL. 

subsided,  under  die  protection  of  a  well-padded  and 
carefully  applied  plaster-of-Paris  dressing. 

In  the  hospital  service  of  the  writer  this  stage  was 
generally  reached  after  the  elapse  of  a  week.  Some- 
times slight  edema  was  set  up  at  first ;  then  the  patient 
was  directed  to  lie  down  at  once,  and  his  lower  ex- 
tremity was  vertically  suspended  until  the  swelling  had 
disappeared.  In  private  practice  it  is  not  advisable  to 
start  the  patient  to  walking  before  at  least  two  weeks 
have  elapsed. 

When  a  circular  plaster-of-Paris  dressing  is  applied, 
it  will  often  be  found  desirable  to  utilize  it  as  a  splint 
after  carefully  taking  it  off.  In  these  cases  the  under- 
layer  of  the  dressings  should  consist  of  muslin  only, 
and  the  bandages  should  be  applied  as  firmly  as  pos- 
sible. As  soon  as  hardened,  the  dressing  is  cut 
through  alongside  a  straight  line,  which  has  previously 
been  marked  with  a  pencil.  To  avoid  injury  of  the 
skin  while  cutting  the  dressing,  it  is  advisable  to  pro- 
tect the  area  below  the  mark  with  strips  of  pasteboard 
or  of  thin  board.  After  the  dressing  is  carefully 
removed,  it  can  be  lined  with  tricot  and  provided  with 
strips. 

Molded  plaster  splints  can  be  made  of  bunches  of 
hemp,  flax,  jute,  or  straw  that  have  been  immersed  in 
a  thin  paste  of  plaster.  After  being  soaked  there  the 
fibers  are  applied  to  the  part,  where  they  are  held  by 
the  turns  of  a  wet  bandage.  The  part  has  first  to  be 
protected  by  oiling.      (Figs.  7,  8,  and  9.) 

These  removable  splints  are  particularly  serviceable 
in  the  treatment  of  compound  fractures.      (See  p.  67.) 

A  special  splint  of  this  kind,  most  useful  in  fractures 
of  the  humerus,  is  the  collar  splint  (Fig.  7),  which  is 


TREATMENT. 


45 


made  by  rolling-  the  plaster  bandages  up  and  down  in 
a  longitudinal  direction,  covering  the  metacarpus,  the 
dorsum  of  the  hand,  and  the  extensor  portion  of  the 
arm  to  the  shoulder  and  the  middle  of  the  neck. 
About  eight  bandage  strips  are  required  for  this  pur- 
pose. When  the  layers  are  thick  enough,  the  neck 
portion  is  reversed  outwardly.  Thus  a  support  is 
gained  for  a  bandage,  which  runs  from  this  improvised 
collar   down   to   the   axilla   of   the    opposite    side.      In 


Fig.   7. — Collar  splint. 

the  same  manner  the  splint  is  fastened  to  the  arm. 
(Fig.  8.) 

If  suspension  of  a  limb  in  a  splint  should  be  consid- 
ered, hooks  or  loops  of  wire  may  be  inserted.    (Fig.  9.) 

The  interrupted  plaster-of- Paris  dressing,  in  pre- 
antiseptic  times  so  very  much  en  vogue,  is  almost 
entirely  abandoned  now,  since  wound  dressings  nowa- 
days need  to  be  changed  but  rarely.  It  is  only  in 
cases  of  sepsis  and  joint  suppuration   that    they  are 


46 


FRACTURES    IN    GENERAL. 


used,  in  order  to  permit  of  frequent  changes  of  the 
wound  dressing  without  causing  the  patient  much 
discomfort.  In  this  method  of  dressing  the  wound 
area  is  overbridged  on  two  sides  by  a  strong  rod  of 
iron,  the  straight  ends  of  which  are  incorporated  in  the 


Fig.  8. — Collar  splint  superficially  fastened  in  fracture  of  the  humerus. 


plaster-of  Paris   dressing,  while  bent  loops  leave  the 
wound    area   free   for    the    application   of   the   wound 

dressing-. 

As  a  substitute  for  plaster-of-Paris,  silicate  of  potas- 
sium is  sometimes  used  (so-called  sodium  dressing). 
Its   advantages   are   its   cheapness   and  lightness  ;    its 


TREATMENT. 


47 


disadvantage  is  that  it  requires  twenty-four  hours  for 
becoming  dry  and  firm.  This  forbids  its  application 
in  fractures  of  recent  origin,  but  in  a  later  stage  its 
employment  may  well  be  considered.  The  manner  of 
application  is  very  simple.  The  silicate  of  potassium 
mixture  having  been  poured  into  a  basin,  a  number  of 
circular  bandages  are  well  soaked  in  it.  Then  the 
bandages  are  put  upon  the  limb  after  the  same  princi- 
ples as  are  observed  in  applying  plaster-of-Paris  dress- 
ings. A  muslin  underlayer  must  be  applied  first  in 
order  to  protect  the  integument. 

The  only  disadvantage  of  the  plaster-of-Paris  dress- 
ing is  that  if  a  swelling  sets  in  underneath,  the  arterial 


Fig.  9. — Molded  plaster  splint  for  the  lower  extremity,  ready  for  suspension. 


supply  becomes  limited,  and  the  muscles  lose  their 
elasticity,  and  may  consequently  become  contracted 
(ischemic  contraction).  Nerves  may  be  injured  in  the 
same  way,  ischemic  paralysis  being  then  the  conse- 
quence. Under  strict  hospital  control  such  outcome 
need  not  be  feared,  since  the  dressing  can  be  cut  off 
as  soon  as  the  first  signs  of  swelling  are  noticed.  But 
most  fractures  are  treated  outside  of  the  hospital, 
where  the  surgeon  must  rely  principally  upon  the  ini- 
tiative of  the  patient.  The  most  unfortunate  feature 
of  such  accidents  is  that  the  stronger  the  pressure 
becomes,  the  more  the  sensation  stops,  so  that  the 
patient  is  then  under  the  fatal  impression  that  his  con- 


48  FRACTURES    IN    GENERAL. 

dition  has  improved,  and  die  necessary  surgical  inter- 
ference is  liable  to  be  unduly  postponed.  It  is  much 
safer,  therefore,  at  least  for  the  surgical  novice,  to  apply 
splints  at  first, — that  is,  during  the  first  week  after  the 
injury, — and  then,  after  the  swelling  has  almost  sub- 
sided, to  substitute  a  plaster-of-Paris  dressing. 

The  number  of  the  different  splints  advised  for  the 
treatment  of  fractures  is  legion.  There  is  hardly  a 
surgeon  of  repute  who  has  not  devised  a  splint  or 
splints  of  his  own.  Most  of  them  are  useful,  but 
under  the  aep-is  of  a  thorough  diagnosis  one  is  sur- 
prised  to  find  how  much  he  can  accomplish  by  choos- 
ing the  simplest  forms  of  splints.  The  limits  of  this 
book  forbid  describing  more  than  a  few  kinds.  A 
splint  consisting  of  simple  board  in  most  cases  is  just 
as  good  as  any  other.  If  lime-wood  (linden  or  bass) 
can  be  procured,  it  should  be  preferred  for  this  pur- 
pose. A  splint  should  be  well  padded  with  muslin  or 
flannel  and  should  extend  over  the  joint  nearest  the  frac- 
ture on  each  side  just  the  same  as  the  plaster-of-Paris 
dressing.  A  dressing  of  this  kind  should  also  be  changed 
at  least  once  a  week.  When,  after  the  elapse  of  a  week, 
the  swelling  has  subsided,  the  dressing  becomes  loose, 
and  the  fragments  may  easily  become  displaced  again. 
Wire  splints  (Fig.  12),  besides  having  the  great 
advantage  of  bein^  made  of  a  li^ht  and  clean  material, 
adapt  themselves  easily  to  the  contours  of  the  body. 
They  are  especially  useful  in  the  treatment  of  com- 
pound fractures.     (See  p.  67.) 

The  fiber  splints,  recently  advised  by  Wiener,  fur- 
nish a  very  convenient  material,  and  the  splints  made 
of  gutta-percha,  porous  or  hatters  felt,  leather,  cellulose, 
or  pasteboard  are  also  serviceable. 


TREATMENT.  49 

Permanent  extension,  best  known  as  Buck 's  ex- 
tension, is  a  simple  and  valuable  means  of  keeping  the 
fragments  in  situ  so  as  to  overcome  shortening.  It  is 
particularly  used  in  fractures  of  the  femur  and  the 
spine,  sometimes  also  in  fractures  of  the  surgical  neck 
of  the  humerus  and  of  the  elbow.  Extension  and 
counterextension  are  exerted  by  the  use  of  a  weight 
and  a  pulley,  the  counterextension  being  made  by  ele- 
vating the  foot  of  the  bed.    (Fig.  10.)    The  weight  must 


Fig.  10. — Extension  dressing  in  fracture  of  the  femur. 

be  the  heavier  the  older  the  individual  and  the  greater 
the  muscular  rigidity  is.  It  may  vary  from  five  to 
twenty-five  pounds.  If  a  light  weight  be  used,  the 
patient  will  stand  the  treatment  better  and  longer;  but 
if  too  little  weight  is  employed,  the  fragments  are  likely 
to  become  displaced.  The  weight  is  suspended  by  a  loop 
made  of  adhesive  plaster  strips,  which  should  extend  up 
to  the  fractured  area.  In  fractures  of  the  femur  a  wide 
adhesive  plaster  strip  should  reach  as  far  up  as  to  the 
4 


5o 


FRACTURES    IN    GENERAL. 


knee-joint,  to  take  off  the  strain  from  the  latter  as  well 
as  to  arrest  motion.  In  order  to  keep  the  plaster  off 
both  malleoli,  a  board  is  inserted  between  the  two 
adhesive  plaster  strips  for  the  purpose  of  keeping 
them  far  asunder,  so  as  to  avoid  decubitus.  (Fig.  1 1). 
In  order  to  obtain  perfect  immobilization  of  the  lower 
lee  and  at  the  same  time  to  avoid  decubitus,  Volkmann 
devised  his  so-called  foot-board.      (Fig.  11.) 


Fie.  II- — Volkmann's  foot-board. 


If  the  adhesive  plaster  is  not  well  borne,  a  filtrated 
sticking  substance  can  be  sprayed  over  the  limb  by  an 
atomizer.*  Two  felt  strips  of  the  width  of  a  hand  are 
applied  in  a  longitudinal  direction.  They  are  fastened 
by  circular  turns  of  a  mull  bandage.  To  the  lower 
ends  of  these  felt  strips  a  canvas  strip  is  attached  to 
serve  as  the  loop  for  the  weight. 

*A  commendable  sticking  mass  of  this  kind  is: 
R. 


Cerse  flavae, 

Resinae  Dammara, 

Colophonii, 

Terebinth,  .    .    .    . 

01.  Terebinthinae, 

Alcohol, 

Ether, 


.  aa  10       parts. 

i.oi  parts. 

.  aa  55        parts. 


TREATMENT.  5  I 

Massage  is  a  splendid  adjunct  in  the  after-treat- 
ment of  fractures.  If  there  is  no  tendency  to  displace- 
ment,— as,  for  instance,  in  the  extraarticular  variety  of 
partial  fracture  of  the  lower  end  of  the  radius, — or  if 
small  portions  of  the  condyles  are  broken  but  still 
remain  in  contact  with  the  bone,  or  if,  in  fracture  of  the 
patella  or  the  olecranon,  no  diastasis  is  present,  mas- 
sage treatment  can  be  commenced  as  early  as  a  few 
days  after  the  injury.  But  whenever  there  is  the 
slightest  tendency  to  displacement,  this  treatment  is 
not  in  order  before  thorough  consolidation  of  the  frag- 
ments  is  warranted. 

To  substitute  massage  entirely  for  the  good  old 
immobilization-treatment,  as  has  been  advocated  re- 
cently, is  not  advisable. 

There  has  lately  been  observable  a  tendency  on  the 
part  of  a  few  surgeons  to  treat  simple  subcutaneous 
fractures  by  wiring  the  fragments.  While  under  the 
auspices  of  asepsis  such  treatment  need  not  be  followed 
by  any  reaction,  and  might  in  the  hands  of  competent 
masters  give  excellent  results  in  suitable  cases,  such 
tendencies  must  be  regarded  as  surgical  aberrations. 
It  is  only  where  much  diastasis  is  present,  as  in  frac- 
ture of  the  patella  (olecranon),  when  bony  union 
appears  improbable,  that  such  rigorous  interference  is 
demanded.  But  by  our  recent  means  of  making  a 
positive  diagnosis  possible  in  all  cases  it  is  usually  just 
as  easy  to  obtain  a  perfect  result  by  a  simple  blood- 
less reduction  and  by  thorough  immobilization. 

Compound  fractures  have  to  be  treated  according 
to  the    principles   of   the    aseptic  wound    treatment. :;: 

*  Compare  the  author's  "  Manual  on  Surgical  Asepsis,"  chap.  II;  W. 
B.  Saunders,  Philadelphia. 


52  FRACTURES    IN    GENERAL. 

To  understand  asepsis  we  must,  first  of  all,  know  the 
factors  which  may  interfere  with  its  thorough  execution. 
They  are  :  The  instruments,  the  dressing-  and  suture 
material  on  the  one  hand,  and,  on  the  other,  the  atmos- 
phere and  the  skin  of  the  patient  and  of  the  surgeon's 
hands.  In  reference  to  the  first  factors  it  can  safely  be 
maintained  that  ideal  asepsis  is  now  an  established  fact. 
All  objects  which  stand  boiling'  well  can  indisputably  be 
made  sterile.  This  also  applies  to  the  much-disputed 
question  of  catgut,  since  Hofmeister  has  shown  us  by 
the  formalin  treatment  how  to  boil  this  material  without 
impairing  its  tensile  strength. 

It  is,  of  course,  to  be  presumed  that  the  sterilization 
of  the  material  in  question  is  supervised  by  the  sur- 
geon himself.  The  process  of  sterilization  must,  in 
other  words,  go  on  in  the  operating  room,  where  the 
sterilizers  must  be  kept.  There  the  towels,  dressings, 
the  suture  material,  etc.,  must  be  taken  from  the  sterilizer 
and  put  directly  upon  the  instrument  table  or  the  body 
of  the  patient.  This  naturally  causes  trouble  for  the 
surgeon,  but  it  is  an  absolute  necessity,  in  view  of  that 
fatal  human  characteristic — forgetful ness. 

The  second  factor,  the  atmosphere,  seemed  to  have 
been  settled  by  the  classic  experiments  of  Schimmel- 
busch,  Petri,  and  Cleves-Symmer.  But  in  consequence 
of  Fluegge's  investigations  *  this  question  has  been  re- 
vived recently,  and  it  seems  to  have  disturbed  the  sur- 
gical mind  unnecessarily.  Theoretically,  the  possibility 
of  atmospheric  infection  can  not  be  disputed;  but  it 
hardly  is  attainable  in  practice.  The  atmosphere,  it  is 
true,  contains  an  enormous  number  of  bacteria,  but 
these  being  innocent  mold,  yeast,   and   fission    fungi, 

*Fluegge,  "  Zeitschrift  fur  Hygiene,"  1897,  Band  xxv. 


TREATMENT.  53 

they  are,  fortunately,  nonpathogenic  for  the  human  race. 
Bacteria  which  are  pathogenic  for  man  are  present  in 
the  atmosphere  only  under  abnormal  conditions  :  as, 
for  example,  when  they  are  stirred  up  from  their  natural 
habitat — the  earth's  surface  or  the  dust  of  the  walls, 
the  floor,  the  tables,  etc.  The  properties  of  the  atmos- 
phere are,  in  fact,  injurious  to  pathogenic  bacteria  in 
every  respect.  The  atmosphere,  if  exceptionally  visited 
by  a  vagabond  pathogenic  bacterium,  can  be  only  a 
temporary  and  most  uncongenial  halting-place  for  it, 
in  which  it  will  soon  be  destroyed.  It  is  a  most  for- 
tunate feature  of  the  pathogenic  bacteria,  especially 
the  pus-producing  variety,  that  they  have  a  marked 
tendency  to  settle.  Wherever  they  settle  they  adhere, 
and  if  they  are  not  provoked,  so  to  say,  by  being 
stirred  up,  they  can  not  come  into  contact  with  a 
wound  any  more. 

According  to  Stern's  experiments,  heavy  bacteria 
settle  to  the  ground  within  the  course  of  an  hour  and 
a  half,  while  the  lighter  ones  require  about  an  hour 
lono-er. 

From  these  facts  we  learn  that  the  bacteria-contain- 
ing dust  in  a  room  should  not  be  stirred  up  by  clean- 
ing and  sweeping  a  few  hours  before  an  operation  is 
to  take  place  there.  As  moisture  precipitates  dust,  it 
is  advisable  to  saturate  the  air  in  the  operating  room 
at  least  during  two  hours  before  the  operation.  This 
can  be  done  by  filling  the  air  with  spray  or  with  steam 
from  a  kettle.  The  windows  should  also  be  kept 
closed,  especially  if  there  is  a  current  of  wind  directed 
toward  them. 

But  another  possible  source  of  infection  propagated 
by  the  atmosphere  deserves  attention.      The  air    ex- 


54  FRACTURES    IN    GENERAL. 

pired  by  the  healthy,  according  to  Tyndall,  does  not 
contain  bacteria,  although  the  cavity  of  the  mouth  is  a 
well-known  gathering-place  for  all  kinds  of  pathogenic 
as  well  as  nonpathogenic  bacteria.  Staphylococci  and 
streptococci  are  nearly  always  found.  It  has,  however, 
been  proved  by  bacteriologic  tests  that  in  healthy  per- 
sons the  virulence  of  these  bacteria  is  very  slight. 
Clinical  observation  is  in  accord  with  this.  But  if  the 
surgeon  suffers  from  tonsillitis  or  even  from  a  rhinitis, 
the  number  as  well  as  the  virulence  of  his  intra-oral 
bacteria  is  remarkably  increased.  If  the  sick  surgeon 
talks  and  coughs  a  great  deal  while  bent  over  the 
wound,  there  is  a  possibility  of  carrying  some  of  these 
bacteria  into  it,  especially  in  an  operation  of  long  dura- 
tion. The  remedy  is  simple,  and  proves  the  wisdom 
of  the  old  saying,  "  Speech  is  silver  and  silence  is  gold." 

The  assistants  in  the  operating  room  must  be  so  well 
drilled  that  they  understand  a  twinkle.  Most  manipu- 
lations can  be  carried  out  as  by  an  automatic  apparatus, 
without  the  need  of  saying  one  word.  Still,  if  the  sur- 
geon is  very  scrupulous,  he  would  best  stop  perform- 
ing important  operations  until  his  recovery  from  the 
ailments  I  have  mentioned. 

Easy  as  the  maintenance  of  asepsis  is  in  regard  to 
the  atmosphere  and  to  all  objects  which  stand  boiling, 
so  is  it  difficult  in  regard  to  the  skin  of  the  patient 
and  the  hands  of  the  surgeon.  Skin-bacteria  are  the 
stumbling-block  in  the  way  of  perfect  asepsis.  The 
undeniable  fact  remains,  that  their  total  destruction  or 
removal  is  practically  impossible. 

The  surface  of  the  human  body  is  impregnated  with 
many  different  bacterial  species.  Some  of  them  adhere 
to  the  skin   surface,  some  are  embedded  in  the  dried 


TREATMENT.  55 

cells  of  the  epidermis.  They  are  all  accessible  to 
sterilization.  They  do  not  necessarily  need  destruc- 
tion, but  removal.  This  can  be  done  by  simple 
mechanical  means — viz.,  scrubbing  with  soap  and 
water.  It  is  made  so  much  the  easier  by  preliminary 
procedures — viz.,  whenever  possible,  the  patient  is 
given  a  warm  bath  twenty-four  hours  before  operation, 
the  field  of  operation  being  scrubbed  with  green  soap 
and  shaved  while  the  patient  is  in  the  bath.  Then  a 
poultice  of  ordinary  green  soap  is  applied  to  the  skin 
until  shortly  before  the  operation.  Thus,  thorough 
permeation  of  the  epidermis — the  dried  cells  of  which 
are,  in  fact,  macerated  by  this  procedure — is  obtained. 
Areas  like  the  perineum,  and  the  scrotal  and  inguinal 
regions,  which  are  particularly  rich  in  glands,  must  be 
scrubbed  with  especial  care.  Before  the  operation  the 
skin  is  scrubbed  energetically  with  linen  compresses 
which  are  dipped  into  hard  fluid  soap.  This  hard 
soap  consists  of  green  soap  mixed  with  soft  sand 
(Stuttgart  sand).  The  scrubbing  process  consumes 
about  two  minutes'  time,  and  goes  on  while  a  stream 
of  very  warm  water  constantly  flows  over  the  surface 
to  be  sterilized.  Then  thin  green  soap  is  used  in  the 
same  manner  and  for  the  same  length  of  time.  Par- 
ticular attention  is  given  to  the  folds  and  creases  of  the 
skin.  Now  the  skin  is  dried  with  an  aseptic  towel,  and 
rubbed  for  one  minute  with  a  gauze  compress  which  is 
saturated  with  fifty  per  cent,  alcohol.  The  alcohol  is 
not  regarded  as  a  disinfectant  in  the  proper  sense,  but 
it  is  mainly  used  for  the  purpose  of  dissolving  the  fat 
of  the  skin,  which  is  a  most  congenial  resting-place  for 
bacteria.  By  dissolving  their  shelter  the  bacteria  are 
naturally  removed. 


56  FRACTURES    IN    GENERAL. 

It  is  self-understood  that  the  means  with  which  asep- 
sis should  be  attained  must  be  aseptic.  This  refers 
particularly  to  the  water  used  for  washing  and  the 
soap,  which  must  have  been  prepared  by  the  boiling 
process.  If  brushes  are  used,  special  care  has  to  be 
taken,  as  they  can  only  with  difficulty  be  rendered 
aseptic,  thorough  cleaning   impairing  their  usefulness. 

Whether  alter  these  procedures  washing  with  bi- 
chlorid  of  mercury  or  lysol  or  similar  disinfectants  is 
still  needed  is  open  to  discussion  ;  it  will  certainly  do 
no  harm. 

There  are  other  similar  methods  of  rendering  the 
surface  of  the  skin  sterile.  If  they  are  thoroughly 
mastered  and  carried  out  minutely,  they  may  be  em- 
ployed just  as  well  ;  but  the  trouble  is  that  under- 
neath the  skin  surface  a  number  of  bacteria  are  shel- 
tered by  the  glands  of  the  skin,  the  secretions  of  which 
offer  a  favorable  soil  for  their  development ;  and  these 
are  not  accessible  to  any  disinfection  or  removal. 
Hence,  other  means  have  to  be  chosen  to  prevent  their 
faculty  of  infection.  And,  in  fact,  they  will  do  little 
harm  if  cared  for  properly. 

It  is  evident  that  in  incising  the  skin  the  knife  dis- 
sects a  number  of  glands  and  thereby  exposes  the 
bacteria  contained  by  these  glands.  This  undeniable 
fact  fully  explains  not  only  the  so-called  suppuration 
of  the  stitch-canals,  many  cases  of  so-called  late  infec- 
tion, and  the  bad  reputation  of  the  catgut,  but  also  most 
of  the  numerous  "  incomprehensible  "  infections  which 
develop  under  the  supervision  of  the  "  extremely 
careful  aseptic  surgeon."  Here  is  also  the  explana- 
tion of  the  suppuration  occurring  "  in  spite  of  the 
most    minute    aseptic    precautions,"   which    not  only 


TREATMENT.  57 

astonished    many  an   experimenter  in  his   laboratory, 
but  also  made  him  set  up  new  surgical  doctrines. 

I  may  take  this  opportunity  to  state  that  bacteri- 
ologic  tests  of  aseptic  methods,  gained  on  artificial 
soil,  can  not  be  applied  to  biologic  processes,  the  living 
cell  reacting  against  bacteria  differently  from  gelatin, 
agar,  or  serum. 

That  the  bacteria  thus  set  free  by  the  skin  incision 
find  the  most  liberal  opportunities  to  come  into  contact 
with  the  deeper  regions  of  the  wound  need  not  be  em- 
phasized. Still,  so  far  as  my  knowledge  goes,  there 
are  no  systematic  precautions  taken  or  advised  in  this 
direction.  If  a  general  can  not  fight  the  enemy  suc- 
cessfully in  the  open  battle-field,  he  tries  to  starve  him 
out,  or  he  may  eventually  overreach  or  circumvent 
him.  And  the  deep-skin  bacteria  can  also  be  circum- 
vented. 

Let  us  consider,  now,  that  the  dissecting  knife  com- 
ing into  intimate  contact  with  these  deep-skin  bacteria, 
generally  represented  by  the  staphylococcus  species, 
must  necessarily  be  regarded  as  infected.  The  hands 
of  the  surgeon  fall  under  the  same  considerations. 
This  indicates  two  necessities — in  the  first  place  the 
change  of  the  infected  knife,  and  secondly  the  re- 
disinfection  of  the  surgeon's  hands.  The  latter  pro- 
cedure may  become  unnecessary  if  gloves  are  worn  by 
the  surgeon  while  the  skin  is  being  incised. 

One  possibility,  however,  remains — inoculation  ol 
the  subcutaneous  strata  with  the  knife.  This  danger 
can  not  be  obviated  entirely,  but  it  can  be  reduced  to 
a  minimum  by  slowly  and  carefully  incising  the  integu- 
ments alone  as  far  as  possible. 

Now,  as  to  the  exposed  skin-bacteria  which  can   not 


58  FRACTURES    IN    GENERAL. 

be  destroyed  or  removed :  how  easy  is  it  to  set  them 
hors  de  combat  by  simple  protection!  Sterile  napkins 
are  fastened  to  the  subcutaneous  tissues  with  miniature 
forceps,  such  as  devised  by  the  author,  so  that  the  skin 
margins  are  so  well  covered  by  them  that  they  do  not 
come  into  view  during  all  the  subsequent  manipula- 
tions, which  are  done  then  on  an  absolutely  sterile 
field. 

After  the  operation  is  completed  the  margins  should 
be  united  by  the  subcutaneous  method.  If  there  is  an 
absolute  necessity  for  relaxation  sutures,  they  should 
be  applied  through  the  skin,  but  about  three-quarters 
of  an  inch  distant  from  the  wound  margin,  so  that 
there  is  no  direct  contact  with  the  wound-line.  For 
such  sutures,  however,  iodoform  silk  should  be  chosen. 
The  same  principle  of  protection  should,  under  proper 
modifications,  be  employed  in  the  opening  of  deep- 
seated  abscesses.  This  principle  was  emphasized  by 
the  author  before,  in  connection  with  the  operation  for 
pyothorax,  in  a  paper  read  before  the  German  Medical 
Society  of  New  York  in  1887.  Then  the  author  had 
tried  to  protect  the  fresh  wound  margins  with  iodoform- 
ether  or  collodion,  before  he  had  opened  the  pleural 
cavity,  in  order  to  prevent  infection  from  the  outflow- 
ing pus.  Very  little  attention  is  paid  to  this  point,  as  is 
evident  from  the  custom  of  incising  abcesses  like  ap- 
pendicial  pus  accumulations,  intraosseous  pus  foci,  etc. 

Once  in  a  while  the  so-called  disposition  to  infection 
is  also  spoken  of.  There  is  something  in  the  theory, 
but  only  in  a  modified  way.  What  favorable  condi- 
tions are,  for  instance,  offered  by  the  skin  of  a  work- 
ing-man ?  And  still,  under  the  most  aggravating  cir- 
cumstances, infection  is  but  seldom  found  among  this 


TREATMENT.  59 

class  in  general,  while  among  the  so-called  better 
classes  the  most  virulent  forms  of  infection  are  ob- 
served, sometimes  after  a  slight  abrasion  of  the  skin. 
This  undeniable  fact  can  not  be  explained  simply  by 
the  difference  of  bacterial  species  or  the  degree  of 
virulence.  The  explanation  must  be  founded  on  bio- 
logic grounds.  It  seems  that  the  plebeian  cell  in  the 
strongly  developed  fist  of  a  laborer  resists,  by  virtue 
of  its  greater  vitality,  the  fiercest  enemy  of  mankind 
more  energetically  than  the  aristocratic  one  in  the 
little-exercised  hand  of  a  man  of  leisure.  On  the 
other  hand,  there  are  a  few  members  of  the  laboring- 
class  who  show  a  most  striking  tendency  for  virulent 
infections — a  fact  which  can  be  explained  by  the 
peculiar  action  of  chemic  influences.  It  certainly 
makes  some  difference  whether  bacteria  are  introduced 
into  the  cell  in  a  pure  state  or  whether  they  are  sus- 
pended in  a  greasy  vehicle.  The  cell  that  is  able  to 
defend  itself  against  the  naked  bacterium,  so  to  say, 
may  be  powerless  against  one  suspended  in  dirty 
machine  oil. 

The  principles  of  sterilization  of  the  surgeon's  hands 
are  practically  the  same  as  those  governing  steriliza- 
tion of  the  skin  of  the  patient.  The  only  essential 
difference  is,  that  the  surgeon's  hands  do  not  need  to 
be  incised,  wherefore  the  deep  bacteria  of  the  skin  of 
his  hand  are  not  exposed,  provided  that  there  are  no 
forcible  efforts  made  to  dislodge  them  and  squeeze 
them  out,  so  to  speak.  This  would,  indeed,  be  pro- 
voked only  by  brutal  manipulations  on  the  part  of  the 
surgeon. 

The  author  has  repeatedly  seen  surgeons  who  had 
taken  scrupulous    care    in    their  aseptic  preparations 


60  FRACTURES    IN    GENERAL. 

handle  the  intestine  in  the  roughest  manner,  permitting 
it  to  come  into  contact  with  the  abdominal  skin  and  its 
wound  margins,  while  manipulating  the  intestine  after 
it  had  been  taken  from  the  abdomen  for  inspection. 
It  speaks  highly  for  the  natural  powers  of  defense  of 
the  human  body,  that  in  spite  of  such  manipulations 
infection  does  not  take  place  in  every  such  instance. 

The  same  modus  operandi  holds  good  for  the  ster- 
ilization of  the  surgeon's  hands,  minus  the  prelimi- 
nary preparations.  The  length  of  time  necessary  for 
the  scrubbing  of  the  surgeon's  hands  may  vary  accord- 
ing to  whether  the  surgeon  had  come  in  contact  with 
septic  cases  shortly  before  sterilization  or  whether  he 
was  positive  that  he  had  remained  clean  for  at  least 
the  last  twenty-four  hours. 

Furthermore,  the  most  particular  care  must  be  given 
to  the  subungual  space.  Wicked  tongues  remark  of 
certain  physicians  that  they  carry  graveyards  under- 
neath their  finger-nails.  To  clean  the  subungual  space 
a  Braatz's  nail-cleaner  is  advisable.  The  nails  must 
be  cut  short  and  even  with  scissors,  not  trimmed  with 
a  file.  The  space  is  then  scrubbed — first  with  the 
rough  soap,  and  then  with  the  alcohol  water. 

It  hardly  needs  mentioning  that  the  surgeon  should 
wash  himself  frequently,  like  other  decent  people, 
whether  he  perform  an  operation  just  at  the  time  or 
not.  In  order  to  protect  himself  as  much  as  possible 
he  should  wear  rubber  eloves  when  coming  in  contact 
with  notorious  bacterial  shelters,  such  as  the  rectum,  or 
when  examining  septic  cases.  He  should  also  wash 
with  especial  care  after  an  operation. 

However,  to  reduce  the  possibility  of  infection  com- 
municated from  deep-skin  bacteria,  gloves  are  advis- 


TREATMENT.  6 1 

able.  Their  use  was  highly  recommended  by  the  author 
as  early  as  in  March,  1895,  in  his  manual  on  "The  Theory 
and  Technique  of  Surgical  Asepsis  "  (Saunders,  Phila- 
delphia), page  94.  It  is  true  that  the  gloves  some- 
times interfere  with  the  technic  of  a  delicate  operation  ; 
sometimes,  however,  they  permit  of  easier  handling — 
as,  for  instance,  in  intestinal  work.  Cotton  gloves 
offer  no  insurance  against  the  action  of  bacteria,  but 
they  act  as  a  kind  of  filter  bag,  or  as  a  bacteria  trap, 
in  which  bacteria  are  not  killed  but  arrested.  When 
gloves  are  not  worn,  it  must  be  remembered  that  the 
hands  of  the  surgeon  should  come  into  contact  with  the 
wounded  area  as  little  as  possible.  Most  manipula- 
tions can  and  must  be  done  with  instruments,  which 
are  always  indisputably  sterile  after  being  boiled.  So, 
for  instance,  a  needle-holder  should  be  used  while  sew- 
ing, instead  of  taking-  the  needle  in  the  hand  ;  thumb- 
forceps  should  be  used  for  holding  tissues,  instead  of 
securing  diem  with  the  fingers. 

Erratic  bacteria  which  are  not  pressed  into  the 
wound  may  perish,  while  in  the  midst  of  heaps  of 
crushed  cells  they  may  develop  in  number  and  viru- 
lence. Thus  may  be  explained  why  some  surgeons 
who  perform  the  dreaded  operation  of  wiring  patellar 
fracture  without  touching  the  wound  surfaces  with  any- 
thing but  instruments  show  splendid  results,  while  the 
experience  of  others  has  been  so  sad  that  they  have 
given  up  the  operation  on  account  of  the  "exception- 
ally great  danger  of  infection." 

These  considerations  bring  us  near  another  most 
delicate  question — namely,  the  surgeon's  manual  dex- 
terity. Since  the  advent  of  the  aseptic  era  it  seems  to 
be  supposed  by  many  that  this  has  become  an  unneces- 


62  FRACTURES    IN    GENERAL. 

sary  accomplishment.  Under  the  auspices  of  asepsis 
countless  technical  sins  are  committed  with  a  light  ani- 
mus.  Some  are  under  the  impression,  for  instance, 
that  if  they  only  stick  to  the  letter  of  aseptic  rules 
they  do  not  need  to  care  for  a  minute  approximation 
— as,  for  instance,  of  the  gut  after  resection.  But  in 
the  event  of  the  slightest  diastasis  the  most  thorough 
aseptic  precautions  prove  to  be  valueless  in  such  a 
case  ;  and,  on  the  other  hand,  the  invasion  of  a  few- 
bacteria  might  have  done  little  harm  if  the  approxima- 
tion was  done  with  great  technical  skill.  How  else 
could  the  miraculous  results  of  some  surgeons  of  the 
preantiseptic  times  be  explained?  The  author  need 
refer  only  to  his  distinguished  teacher,  Bernhard  von 
Langenbeck,  the  results  of  whose  plastic  operations 
astonished  the  world.  And  his  classic  rules  for  plastic 
operations  were  outlined  long  before  the  days  of 
antisepsis. 

Whoever  saw  von  Langenbeck  operate  must  have 
had  the  impression  that  he  was  an  aristocrat  in  the  best 
sense  of  the  word.  He  had  a  most  pronounced  sense 
for  natural  cleanliness.  It  was  not  customary  at  his 
clinic  to  wear  sterile  gowns  before  the  introduction  of 
antiseptic  rules,  but  the  students  wondered  why  the 
master,  while  operating,  always  wore  a  long,  peculiarly 
made  Prince  Albert  coat,  which  fitted  high  over  the 
neck.  This  coat  was  always  cleaned  very  thoroughly, 
sometimes  to  the  disappointment  of  the  operating 
nurse.  There  was  a  great  contrast  to  the  nonesthetic 
customs  at  other  clinics  of  the  same  period.  The 
hands  were  frequently  washed,  and  the  instruments, 
sponges,  and  the  ligature  material  were  kept  extremely 
clean.     Von  Langenbeck's  technic  was  that  of  an  artist. 


TREATMENT.  63 

His  work  was  as  delicate  as  a  watchmaker's.  His 
anatomic  knowledge  enabled  him  to  make  his  skin  in- 
cision in  conformity  with  the  deep  seat  of  the  lesion 
which  indicated  the  operation.  Naturally,  he  could 
also  carry  out  his  steps  rapidly.  Thus,  by  the  short 
duration  of  his  operation  he  exposed  his  patient  to  a 
smaller  risk  of  infection.  His  gen  tie  handling  of  the 
tissues  in  general,  his  aversion  to  blunt  operating, 
his  predilection  for  sharp  and  clean  instruments,  were 
all  points  which  counterbalanced  to  a  certain  degree 
the  preantiseptic  shortcomings.  Such  accomplishments 
should  by  no  means  be  regarded  as  unimportant  in  this 
modern  era.  The  surgeon  should  strive  zealously  to 
come  as  near  to  such  perfection  as  possible. 

Thus  we  can  see  that  the  success  of  aseptic  surgery 
does  not  depend  upon  a  few  principles,  but  that  it  is 
the  happy  combination  of  scientific  knowledge,  con- 
science, and  manual  skill  which  makes  the  surgical 
master,  who  must  thoroughly  understand  and  regulate 
the  thousandfold  different  wheels  of  that  wonderful 
organic  clockwork — man. 

If  we  translate  our  considerations  now  into  practice, 
the  following  maxims  will  result : 

1.  The  superficial  surface  of  the  skin  of  the  patient 
and  of  the  surgeon's  hands  is  sterilized  after  the  princi- 
ples set  forth  above.  The  atmosphere  being  innocuous, 
all  inorganic  material  being  made  aseptic  by  boiling, 
the  skin  surface  being  ascepticized,  and  the  skin-glands 
that  contain  bacteria  beino"  hors  de  combat,  it  becomes 
evident  that  the  only  possible  source  of  infection 
remaining  would  be  rough  manipulation  on  the  part 
of  the  surgeon  or  of  his  assistants. 

2.  Aseptic  gloves  are  worn  by  the  operating  surgeon 


64  FRACTURES    IN    GENERAL. 

at  least  during  the  skin  incision.  The  assistant  who 
passes  the  instruments  and  the  one  who  attends  to  the 
wound  itself  wear  gloves  throughout  the  whole  opera- 
tion. 

3.  After  incision  the  wound  margins  of  the  skin  are 
covered  with  sterile  napkins,  which  are  fastened  to  the 
wound  surface  underneath  the  skin  margins  with  mini- 
ature forceps,  so  that  the  skin  wound  is  not  touched  at 
all  during  the  subsequent  manipulations. 

4.  The  knife  used  for  the  skin  incision  must  not  be 
used  for  further  incisions.  The  operation  should  be 
performed  as  rapidly  as  possible. 

5.  For  uniting  the  wound  margins  of  the  skin  the 
subcutaneous  method  should  be  preferred. 

6.  Forcible  manipulations,  especially  blunt  operating, 
should  be  avoided.  Hemostasis  must  be  very  thor- 
ough. 

7.  The  surgeon  and  assistants  wear  sterilized  suits 
or  gowns.  Their  heads  must  be  covered  with  sterilized 
caps,  because  in  bending  over  the  field  of  operation  it 
often  happens  that  the  heads  of  the  surgeon  and  his 
assistant  come  in  contact,  whereby  infectious  material 
might  be  introduced  into  the  wound. 

8.  Long  beards  are  entirely  unsurgical. 

9.  If  a  surgeon  should  suffer  from  rhinitis,  tonsillitis, 
etc.,  he  should  use  the  most  minute  local  precautions, 
or  would  better  omit  operating  until  recovery.  It  is 
self-understood  that  a  surgeon  should  regard  it  as  a 
crime  to  operate  as  long  as  he  suffers  even  from  a 
slight  furuncle  on  his  hand. 

With  the  expenditure  of  a  little  more  time  and 
trouble  the  same  principles  can  be  carried  through  in 
private  practice  also. 


TREATMENT.  65 

In  case  of  shock  hypodermic  saline  infusions  should 
be  made. 

Whether  a  compound  fracture  is  a  priori  infected  or 
not  can  hardly  be  proved.  The  state  of  a  compound 
fracture  may  with  some  probability  be  regarded  as 
aseptic  if  the  person  who  sustained  it  and  the  wound- 
ing object  were  both  clean,  and  if  but  little  time  had 
elapsed  before  it  came  under  the  observation  of  a  sur- 
geon. Still,  whether  aseptic  or  not,  the  principles  of 
prophylactic  disinfection  and  the  carrying-out  of  the 
disinfecting  process  remain  the  same,  as  previously 
described.      (See  p.  52.) 

If  there  should  be  but  a  small  wound,  the  surfaces 
of  which  will  agglutinate  before  infection  is  possible, 
union  by  first  intention  is  often  secured,  provided  the 
premises  of  secondary  infection  are  removed  by  the 
prophylactic  disinfection.  The  further  course  of  such 
fractures  does  not  differ  from  that  of  a  simple  subcu- 
taneous fracture. 

But  if  there  is  extensive  injury  to  the  soft  tissues, 
splintering  of  bones,  perforation  into  a  joint,  etc.,  a 
large  incision  should  be  made.  An  attempt  should 
always  be  made  to  first  locate  the  splinters  by  the 
Rontgen  rays.  The  loose  splinters  must  be  extracted, 
while  those  that  still  maintain  an  attachment  to  the 
periosteum  should  be  left.  Fragments  of  fat,  muscu- 
lar shreds,  fascia  or  crushed  skin,  and  other  debris 
should  also  be  removed.  Projecting  points  of  bone 
should  be  trimmed  off  with  bone-forceps.  If  the  bone- 
fragments  show  much  tendency  to  displacement,  they 
should  be  wired  or  nailed  together.  (See  technic  of 
wiring,  p.  69.) 

All  hemorrhage  must  be  carefully  arrested  ;  foreign 
5 


66  FRACTURES    IN    GENERAL. 

bodies — such  as  splinters  of  wood,  glass,  and  bullets — 
are  to  be  extracted.  Pockets  underneath  the  integu- 
ment are  split  wide  open.  These  manipulations 
should  be  performed  only  while  irrigation  with  a  o.  i 
per  cent,  sublimate  solution  is  maintained.  If  neces- 
sary, counteropenings  are  to  be  made,  so  as  to  permit 
the  introduction  of  thorough  drainage.  Great  care  must 
be  taken  that  the  drains  do  not  come  between  the 
bone-fragments.  It  is  inadvisable  to  apply  sutures  to 
wounds  of  this  kind.  After  small  rubber  drains,  sur- 
rounded by  iodoform  gauze,  are  introduced  into  the 
counteropenings,  the  wound  cavity,  especially  the 
pockets,  is  extensively  packed  with  iodoform  gauze. 
The  wound  is  further  protected  with  a  large  amount 
of  some  sterile  and  absorbent  material.  The  most  de- 
sirable substance  for  this  purpose  is  moss-board,  made 
of  common  German  moss,  the  absorbent  power  of 
which  is  five  times  as  great  as  that  of  gauze.  It  rep- 
resents a  very  soft  and  adaptable  material,  and  it  can 
be  very  easily  sterilized.  It  is  used  best  by  being 
compressed  into  a  tablet-like  shape.  (Fig.  23.)  It  can 
also  be  used  loose,  after  being  put  into  gauze  bags,  but 
it  then  loses  its  most  convenient  property — its  immo- 
bilization power.  The  moss-board,  after  being  dipped 
into  cold  water,  adapts  itself  to  the  contours  of  the 
body  like  a  plaster-of-Paris  splint,  over  which  it  pos- 
sesses the  great  advantages  of  being  absorbent  and 
much  lighter.  (Fig.  23.)  The  bulky  species  of  moss- 
board  makes  an  ideal  splint ;  for,  should  the  wound  dis- 
charge exceed  the  absorbent  power  of  the  gauze  directly 
over  the  wound,  it  takes  up  the  superfluous  discharge 
without  impairing  the  usefulness  of  the  moss  as  an 
immobilizing  factor.     To  make  a  moss  splint  adaptable 


TREATMENT. 


67 


it  must  be  dipped  into,  and  not  soaked  in,  cold  water. 
If  warm  water  is  taken,  the  moss  will  swell  up  rapidly 
and  the  immobilization  power  is  lost.  If  the  secretion 
becomes  abundant,  the  center  of  the  moss-board,  by 
absorbing  it,  swells  up  naturally,  but  there  is  so  large 
a  portion  of  the  molded  moss  splint  left  that  its  value 
as  an  immobilizing  apparatus  does  not  become  im- 
paired, any  more  than  does  a  plaster-of-Paris  dressing 
by  the  cutting  of  a  fenestra. 

Immobilization  will  be  so  much  the  more  reliable  if 
a  large  wire  splint  is  adapted  besides.*     (Fig.  12.) 

In  case  there  is  an  indication  for  antiseptic  lotions 
the  wire  splint  does  not  conflict  with  their  applica- 
tion.     If   this   splint,   after  being  boiled    and    loosely 


Fig.  12. — Simple  wire  splint. 


covered  with  sterilized  gauze,  is  adjusted  by  a  gauze 
bandage,  it  represents  an  absolutely  sterile  and  per- 
meable material.  Putrid  cavities  are  packed  with  some 
antiseptic  gauze  (iodoform  gauze)  ;  besides,  a  strong 
antiseptic  drug  should  exercise  a  continuous  influence. 
This  will  be  accomplished  if  a  strong  bichlorid  solu- 
tion is  poured  on  the  gauze  dressing,  which  is  thus 
kept  permanently  moist,  the  bichlorid  solution  coming 
continuously  into  direct  contact  with  the  wound  sur- 
face. Accordingly,  in  well  granulating  wounds  the 
dry  treatment  (iodoform  gauze,  moss  splint,  and  over 
this  the  wire  splint)  should  be  preferred.  But  if 
there  be  a  putrid  cavity,  the  moist  method  (iodoform 

*  See  the  author's  "  Manual  on  Asepsis,"  p.  200. 


68  FRACTURES    IN    GENERAL. 

gauze  packing  and  padded  wire  splint  only)  should 
be  selected.  For  small  wounds,  provided  there  are 
good  granulations,  a  fenestrated  circular  plaster-of- 
Paris  dressing  may  be  used  and  the  wound  may  be 
treated  through  the  fenestra.  (Compare  Fig.  5.) 
The  same  method  may  be  selected  when  large  wounds 
which  have  formerly  had  a  putrid  character  have  lost 
their  virulence  under  the  influence  of  a  moist  anti- 
septic dressing. 

Under  this  treatment  many  cases  heal  that  formerly 
were  destined  to  amputation.  Still,  there  are  cases  in 
which  the  soft  tissues  are  so  extensively  destroyed  that 
conservative  treatment  may  fail  of  success.  In  some 
cases  there  may  be  such  extensive  crushing  and  splin- 
tering that,  from  the  very  beginning,  the  preservation 
of  the  limb  is  out  of  the  question,  and  amputation  has 
to  be  resorted  to.  Such  an  extreme  course  fortunately 
represents  at  present  but  a  small  percentage  of  cases. 
Nowadays  the  surgeon  should  amputate  only  after  hav- 
ing considered  all  the  pros  and  cons  most  carefully. 

During  the  treatment  of  a  compound  fracture  the 
patient  has  to  be  observed  thoroughly.  Great  stress 
must  be  laid  on  taking  the  morning  and  evening 
temperature  regularly. 

As  far  as  the  change  of  the  dressings  in  compound 
fractures  is  concerned,  the  tendency  at  present  is  to 
disturb  them  as  rarely  as  possible.  The  main  indica- 
tions for  change  of  dressing  are  : 

1.  When  stitches  or  drainage-tubes  require  removal. 

2.  When  secondary  hemorrhage  occurs. 

3.  When  the  discharge  becomes  so  abundant  that  it 
can  not  be  absorbed  by  the  dressings,  and  a  conse- 
quent transudation  to  the  surface  takes  place. 


TREATMENT.  69 

4.  When  the  dressing  has  been  so  disturbed  or 
moved  that  either  the  protection  of  the  wound  be- 
comes imperfect  or  there  is  risk  of  contamination  by 
urine,  feces,  etc. 

'5.  When  the  patient  complains  of  intense  pain. 

6.  When  fever  sets  in  and  general  symptoms  point 
toward  infection. 

7.  When  there  is  any  doubt  as  to  the  character  of 
the  fever. 

In  case  of  non-union  the  fragments  must  be  sutured 
together  with  silver  wire  (Fig.  13  a)  or  very  stout  cat- 
gut. To  accomplish  this,  holes  are  bored  near  the  ends 
of  the  fragments  with  a  strong  drill.  Through  these 
holes  the  suture  material  is  drawn,  and  the  fragments 
are  then  pulled  together.  Greater  security  of  adapta- 
tion is  obtained  by  resecting  the  bone-ends  in  a  stair- 
case-like shape.     (Fig.  13  b.) 

Good  approximation  may  also  be  obtained  by  using 
long,  four-cornered,  well-polished  nails,  with  which  the 
fragments  are  nailed  together.  The  nails  must  pro- 
ject to  the  extent  of  nearly  an  inch  beyond  the  level  of 
the  integument.  Steel  is  the  best  material  for  nails,  and 
should  be  preferred  to  ivory  ;  not  only  because  steel 
nails  can  easily  be  rendered  sterile  by  boiling,  but  be- 
cause they  can  be  extracted  much  more  easily,  while 
the  ivory  pegs  become  so  decalcified  after  a  little  while 
by  the  carbonic  acid  in  the  tissues  that  they  become 
rough  and  their  extraction  is  thereby  made  difficult. 

Instead  of  nailing  the  fragments  together,  insertion 
of  an  ivory  peg  into  the  medullary  cavity  of  the  frag- 
ments may  be  employed. 

Implantation  is  another  ingenious  method.  It  con- 
sists in  pointing  the  thinnest  of  the  two  fragments,  so 


7o 


FRACTURES    IN    GENERAL. 


that  it  can  be  inserted  into  the  medullary  cavity  of  the 
other  and  larger  fragment.     (Fig.  13  c.) 

Simple  fractures  may  exceptionally  be  converted 
into  compound  fractures  on  account  of  great  muscular 
spasm,  from  necrosis  of  a  small  fragment,  or  from  the 
different  sources  of  infection.  The  writer  has  observed 
three  cases  of  suppuration  in  simple  fractures  of  the 
femur,  the  subjects  of  which  were  boys  of  four,  five, 


Fig.  13. — a,  Bone-suture  ; 


b,  staircase-shaped  exsection  ;   c,  implantation  of 
bone-ends. 


and  seven  years.  They  all  suffered  from  tubercular 
inflammation  of  the  adjacent  knee-joint,  the  suppura- 
tion settino-  in  between  the  second  and  third  week 
after  the  accident.  Free  incision  becomes  imperative 
in  such  cases  ;  after  which  treatment  will  be  the  same 
as  before  advised.      (See  p.  65.) 

Treatment  of  Disturbances  in  the  Process  of 
Repair. — In  discussing  this  subject  we  shall  do  best 
to    follow  up  the  instances  given   under  the  heading 


^  A  T  TMnT-7 P  Qf  Arranged  in  Question  and 

^-^  Answer  Form. 

V^  U  J      }  1  1V-/1N  nrrHE  MOST  COMPLETE  AND  BEST 

r^OMPFNTHQ  ILLUSTRATED  SERIES  OF 

V^wlVlx-^Cl\|.LO  COMPENDS  EVER  ISSUED. 

Now  the  Standard  Authorities  in  Medical  Literature  .... 

with  Students  and  Practitioners  in  every  City  of  the  United  States  and  Canada. 


O- 


OVER  175,000  COPIES  SOLD.    ^ 


^» 


THE  REASON  WHY. 

They  are  the  advance  guard  of  "Student's  Helps" — that  DO  help.  They  are  the 
leaders  in  their  special  line,  well  and  authoritatively  written  by  able  men,  who,  as  teachers  in 
the  large  colleges,  know  exactly  what  is  wanted  by  a  student  preparing  for  his  examinations. 
The  judgment  exercised  in  the  selection  of  authors  is  fully  demonstrated  by  their  professional 
standing.  Chosen  from  the  ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of 
them  have  become  Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250  pages, 
profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on  fine  paper. 

The  entire  series,  numbering  twenty-three  volumes,  has  been  kept  thoroughly  revised 
and  enlarged  when  necessary,  many  of  the  books  being  in  their  fifth  and  sixth  editions. 

TO  SUM  UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  market,  none  of 
them  approach  the  "Blue  Series  of  Question  Compends;"  and  the  claim  is  made  for  the 
following  points  of  excellence  : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Quality  of  illustrations,  paper,  printing,  and  binding. 

Any  of  these  Compends  will  be  mailed  on  receipt  of  price  (see  next  page  for  List). 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  Street.  Philadelphia. 


Oaunders'  V^uestion-Compend  Oeries* 


Price,  Cloth,  $J.OO  per  copy,  except  when  otherwise  noted. 

"  Where  the  work  of  preparing  students'  manuals  is  to  end  we  cannot  say,  but  the 
Saunders  Series,  in  our  opinion,  bears  oft"  the  palm  at  present." — New  York  Medical  Record. 


1.  ESSENTIALS  OF  PHYSIOLOGY.     By  H.  A.  Hare,  M.D.     Fourth  edition, 

revised  and  enlarged.      (#1.00  net.) 

2.  ESSENTIALS  OF   SURGERY.     By  Edward  Martin,  M.D.      Sixth  edition, 

revised,  with  an  Appendix  on  Antiseptic  Surgery. 

3o    ESSENTIALS   OF   ANATOMY.     By   Charles   B.    Nancrede,  M.D.      Sixth 
edition,  thoroughly  revised.      ($1.00  net.) 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

By  Lawrence  Wolff,  M.  D.     Fifth  edition,  revised.     ($i.oo  net.) 

5.  ESSENTIALS  OF  OBSTETRICS.     By  W.  Easterly  Ashton,  M.D.     Fourth 

edition,  revised  and  enlarged. 

6.  ESSENTIALS  OF  PATHOLOGY  AND  MORBID  ANATOMY.     By  C.  E. 

Armand  Semple,  M.D. 

7.  ESSENTIALS  OF  MATERIA  MEDICA,  THERAPEUTICS,  AND   PRE- 

SCRIPTION=WRITING.    By  Henry  Morris,  M.D.     Fifth  edition,  revised. 

8.  9.    ESSENTIALS   OF    PRACTICE   OF   MEDICINE.      By   Henry   Morris, 

M.D.  An  Appendix  on  Urine  Examination.  By  Lawrence  Wolff,  M.D. 
Third  edition,  enlarged  by  some  300  Essential  Formulne,  selected  from  eminent 
authorities,  by  Wm.  M.  Powell,  M.D.      (Double  number,  $2.00.) 

10.  ESSENTIALS  OF  GYN/ECOLOGY.      By  Edwin  B.  Cragin,  M.D.      Fourth 

edition,  revised. 

11.  ESSENTIALS  OF  DISEASES  OF  THE  SKIN.     By  Henry  W.  Stelwagon, 

M.  D.     Fourth  edition,  revised  and  enlarged.      (#1.00  net.) 

12.  ESSENTIALS  OF  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 

DISEASES.     By  Edward  Martin,  M.D.     Second  ed.,  revised  and  enlarged. 

13.  ESSENTIALS  OF  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 

By  C.  E.  Armand  Semple,  M.D. 

14.  ESSENTIALS  OF   DISEASES  OF  THE   EYE,  NOSE,  AND  THROAT. 

By  Edward  Jackson,  M.D. ,  and  E.  B.  Gleason,  M.D.     Second  ed.,  revised. 

15.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.     By  William  M.  Powell, 

M.D.     Second  edition. 

16.  ESSENTIALS   OF   EXAMINATION   OF   URINE.     By   Lawrence  Wolff, 

M.D.     Colored  "  Vogel  Scale."     (75  cents.) 

1 7.  ESSENTIALS  OF  DIAGNOSIS.     By  S.  Solis  Cohen,  M.D. ,  and  A.  A.  Eshner, 

M.D.      (#1.50  net.) 

18.  ESSENTIALS  OF  PRACTICE   OF   PHARMACY.     By   Lucius   E.    Sayre. 

Second  edition,  revised  and  enlarged. 

20.  ESSENTIALS  OF  BACTERIOLOGY.     By  M.  V.  Ball,  M.D.     Third  edition, 

revised. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY.     By  John  C. 

Shaw,  M.D.     Third  edition,  revised. 

22.  ESSENTIALS  OF   MEDICAL  PHYSICS.      By   Fred  J.    Brockway,    M.D. 

Second  edition,  revised.      ($1.00  net.) 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.    By  David  D.  Stewart,  M.D., 

and  Edward  S.  Lawrance,  M.D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE   EAR.      By  E.  B.  Gleason,  M.D. 

Second  edition,  revised  and  greatly  enlarged. 


Pamphlet  containing  specimen  pages,  etc.  sent  free  upon  application. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  Street,  Philadelphia, 


TREATMENT.  7  I 

Disturbances  in  the  Process  of  Repair  (p.  31),  where 
the  causes  and  consequences  of  these  disturbances  are 
discussed. 

Pseudoarthrosis  is  sometimes  successfully  treated  by 
electrolysis.  Nailing  the  bones  together  with  ivory 
pegs  is  naturally  more  effective.  But  the  safest  way 
is  resection.  The  ends  of  the  fragments  should  be 
freshened  and  then  sewed  together  with  silver  wire 
(Fig.  13  a)  or  stout  catgut,  as  described  on  page  69. 
If  there  is  much  tendency  to  displacement,  the  ends 
may  be  resected  in  the  form  of  steps,  in  order  to  make 
them  fit  closer.  (Fig.  13  d.)  The  insertion  of  a 
pointed  bone-end  into  the  medullary  cavity  of  the 
other  fragment  may  also  be  considered.  (Fig.  13  c.) 
In  light  cases  energetically  rubbing  the  ends  of  the 
bones  together  daily  sometimes  sets  up  so  much  local 
reaction  that  callus  formation  is  induced.  The  produc- 
tion of  moderate  venous  hyperemia  by  the  use  of  a 
rubber  tourniquet  is  also  recommended.  The  same 
procedure  may  be  used  in  cases  of  late  union. 

Gangrene  has  to  be  treated  after  the  principles  set 
forth  on  page  68. 

Aneurysm  has  to  be  treated  after  general  surgical 
principles. 

Compression  of  a  nerve  may  be  relieved  by  exposing 
it  freely  ;  a  wide  incision  being  necessary  if  the  nerve 
should  be  surrounded  by  much  callus  proliferation, 
which  latter  should  be  chiseled  away.  After  such  in- 
terference perfect  recovery  has  been  observed  in  a 
number  of  cases.     (Figs.  66,  67.) 

Embolism  has  to  be  treated  after  general  medical 
principles,  stimulation  of  the  heart  being  the  main  fac- 
tor (digitalis,  caffein). 


/  2  FRACTURES    IN    GENERAL. 

Ankylosis  offers  but  poor  chances  for  complete  resti- 
tution. The  bony  variety  (compare  Fig.  118)  requires 
osteotomy,  combined  with  the  exsection  of  a  bone- 
wedge.  In  fibrous  ankylosis  repeated  forcible  motion 
and  manual  correction  of  the  abnormal  position  under 
anesthesia  sometimes  yield  fair  results,  provided  much 
time  has  not  elapsed  since  the  injury  was  sustained. 
Massage  treatment  is  also  a  potent  factor. 

But  the  most  good  can  be  done  by  early  prophylaxis. 
If  a  fracture  is  situated  in  the  vicinity  of  a  joint,  so  that 
ankylosis  is  to  be  feared,  the  latter  will  certainly  be 
avoided,  if  massage  and  active  and  passive  motion  are 
employed  as  soon  as  the  swelling  has  subsided. 

Delirium  tremens  must  be  treated  mainly  by  prophy- 
lactic measures.  Alcohol  (wine,  whisky)  should  be 
given  in  moderate  quantities  to  such  individuals  as  are 
accustomed  to  its  use.  A  ligfht  diet  should  be  observed. 
Opium  and  chloral  in  large  doses  may  be  freely  ad- 
ministered. Patients  who  give  an  alcoholic  history 
should  be  induced  to  walk  about  as  early  as  possible. 
(See  p.  42.) 

Pneumonia  is  treated  after  general  medical  princi- 
ples. The  main  factor  in  this  connection  is  also  pro- 
phylaxis. Aged  persons  especially  must  walk  about 
as  soon  as  possible.  If  in  bed,  their  positions  must  fre- 
quently be  changed.  In  fractures  of  the  lower  extrem- 
ity, if  walking  in  a  plaster-of-Paris  dressing  (compare 
Fig.  6)  should  prove  to  be  inopportune,  extension 
should  be  employed  when  aged  people  are  concerned. 
When  patients  of  advanced  years  can  not  be  allowed 
to  walk  it  is  best  to  let  them  sit  up  in  bed  as  much  as 
possible,  in  order  to  prevent  circulatory  stasis  and  its 
train  of  evil  consequences. 


PECULIARITIES    OF    FRACTURES    IX    CHILDREN.  73 

PECULIARITIES  OF  FRACTURES  IN 
CHILDREN. 

Although  fractures  in  children  must  practically  be 
considered  from  the  same  standpoint  as  those  in 
adults,  they  present  some  characteristic  deviations, 
which  deserve  a  special  description. 

Among  the  more  marked  varieties  of  infantile  frac- 
tures the  intrauterine  and  congenital  and  the  rickety 
and  spontaneous  types  may  be  mentioned.  Almost 
peculiar  to  infancy  and  childhood  are  separation  of  the 
epiphysis  and  the  so-called  "  greenstick  "  fracture. 
(Fig.  90.)  It  may  be  added  that  the  scapula,  sternum, 
and  pelvis  are  but  seldom  fractured  in  childhood,  while 
the  clavicle,  humerus,  radius,  thigh,  and  leg  are  more 
frequently  involved  than  in  adults.  Fractures  of  the 
finorers,  ^ne  skull,  and  the  maxillas  are  also  much  rarer 
in  childhood. 

In  intrauterine  fractures  (see  Figs,  i,  2,  and  93) 
normal  union  takes  place  in  a  large  number  of  cases. 
Sometimes  there  is  no  union  at  all,  and  often  a  greater 
or  lesser  degree  of  deformity  is  observed. 

Congenital  fractures  are  of  moderate  frequency. 
For  detailed  description  see  Part  II. 

True  epiphyseal  separation — that  is  to  say,  a  real 
chondro-epiphyseal  division  (Fig.  50),  where  the  epi- 
physeal cartilage  is  sharply  severed  from  the  osseous 
end  of  the  diaphysis — occurs  in  infants  only,  and  is 
extremely  rare,  while  osteo  epiphyseal  separation  (Fig. 
49)  is  frequently  observed  between  the  ages  of  four- 
teen and  seventeen.  In  these  latter  cases  the  fracture 
line  is  not  limited  to  the  epiphyseal  cartilage,  but 
extends  to  the  diaphysis.     Traumatic  separation  has  a 


74  FRACTURES    IN    GENERAL. 

marked  predilection  for  the  epiphyses  of  the  upper 
and  lower  ends  of  the  humerus,  the  lower  end  of  the 
radius,  and   the  lower  ends  of  femur  and  tibia. 

The  different  epiphyses  naturally  show  a  tendency 
to  separation  at  various  times.  The  dates  of  ossifica- 
tion and  union  of  the  epiphyses  of  the  humerus,  radius, 
femur,  and  tibia  are,  according  to  Ouain  : 

In  the  humerus  the  nucleus  of  the  head  appears  in 
the  second,  of  the  capitellum  in  the  third,  of  the  inter- 
nal condyle  in  the  fifth,  of  the  trochlea  in  the  eleventh, 
and  of  the  external  condyle  in  the  fourteenth  year  (see 
Fig.  174),  while  union  between  the  lower  epiphysis  and 
the  diaphysis  takes  place  between  the  sixteenth  and 
eighteenth  years,  and  between  the  upper  epiphysis  and 
the  diaphysis  in  the  twentieth  year.  The  lower  epiphysis 
of  the  humerus  consists  of  four  nuclei,  which  ossify  and 
unite  between  the  eighth  and  eighteenth  years,  a  fact 
that  is  of  great  importance  in  the  correct  interpretation 
of  skiagraphs.  In  theradius  (see  Fig.  87)  the  nucleus 
of  the  lower  end  appears  at  the  end  of  the  second  year, 
while  that  of  the  head  follows  at  the  fifth.  The  upper 
epiphysis  and  the  diaphysis  unite  between  the  seven- 
teenth and  eighteenth  years,  and  the  lower  epiphysis 
and  diaphysis  join  in  the  twentieth  year.  The  nucleus 
of  the  lower  end  of  the  femur  (see  Fig.  138)  appears 
as  early  as  at  the  ninth  month,  while  that  of  the  head 
shows  at  the  end  of  the  first  year.  The  head  unites 
with  the  diaphysis  at  the  eighteenth  or  nineteenth  year, 
and  the  lower  epiphysis  follows  after  the  twentieth  year. 
The  upper  epiphysis  of  the  tibia  (see  Fig.  138)  appears 
at  the  time  of  birth,  while  the  lower  one  shows  in  the 
second  year.  The  lower  tibial  epiphysis  unites  with  the 
diaphysis  between  the  eighteenth  and  the  nineteenth 


THE  AMERICAN  YEAR-BOOK 
OF  MEDICINE  AND  SURGERY. 

Edited  by  George 
M.  Gould,  M.D. 
Vols,  for  J  896, 
'97,  '98,  and  '99, 
handsome  oc- 
tavo volumes  of 


SAUNDERS' 
AMERICAN 
YEAR-BOOK  OF 
MEDICINE  AND 
SURGERY 


1200  pages.  Cloth,  $6.50  net;  Half 
Morocco,  $7.50  net.  Year-Book  for 
1900  in  two  volumes,  about  600  pages 
each.  Per  vol. :  Cloth,  $3.00  net ;  Half 
Morocco,  $3.75  net.     Sold  separately. 

IN  2  VOLS.    NO  INCREASE  IN  PRICE. 

A  yearly  digest  of  scientific  progress  and  authori- 
tative opinion  in  all  branches  of  Medicine  and 
Surgery,  drawn  from  journals,  monographs,  and 


"We  have  very  carefully  gone  through  this 
work,  and  repeatedly  tested  the  claim  set  forth 
that  no  significant  fact  has  been  omitted.  This 
claim  is  amply  justified,  and  we  unhesitatingly 
recommend  it  to  the  medical  profession  as  an 
unique  and  invaluable  summary  of  the  progress 
made  in  medical  science  uuring  the  past  year." — 
Quarterly  Medical  Journal,  Sheffield,  England. 


text-books  of  the  leading  American  and  foreign 
authors  and  investigators.  Collected  and  ar- 
ranged, with  critical  editorial  comments,  by  28 
eminent  American  Specialists  and  Teachers.  «£* 

Send  post-paid  on  receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


AMERICAN 
TEXT-BOOK 
OF  DISEASES 
OF  THE  EYE, 
EAR,  NOSE, 
AND  THROAT 


An  American  Text -Book  of   DISEASES 

OF  THE  EYE,  EAR,  NOSE,  AND 
TKROAT.  Contributions  from  60 
prominent  Ameri- 
can  Specialists, 
Edited  by  G.  E.  de 
Schweinitz,  A.M., 
M.D.,  Professor  of 
Ophthalmology, 
Jefferson  Medical 
College,  Philadelphia;  and  B.  Alex. 
Randall,  A.M.,  M.D.,  Clinical  Profes- 
sor of  Diseases  of  the  Ear,  University 
of  Pennsylvania.  Imperial  octavo. 
\ 251  pages,  766  illustrations,  59  in 
colors.  Cloth,  $7.00  net;  Sheep  or 
Half  Morocco,  $8.00  net.  &  J>  Jt  J, 
JUST  ISSUED. 

The  present  work  makes  a  special  claim  to  favor 
based  on  an  encyclopedic,  authoritative,  and 
practical  treatment  of  the  subjects.  Each  section 
of  the  book  has  been  entrusted  to  an  author  es- 
pecially identified  with  the  subject,  who  there- 
fore presents  his  case  in  the  manner  of  an  expert. 
Particular  emphasis  is  laid  on  the  most  approved 
methods  of  treatment,  so  that  the  book  shall  be 
one  to  which  the  student  and  practitioner  can 
refer  for  information  in  practical  work.  <£  <£  <£ 

Send  post-paid  on  receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


PECULIARITIES    OF    FRACTURES    IN    CHILDREN.  75 

years,  while  the  upper  epiphysis  unites  with  the  di- 
aphysis  in  the  twentieth  or  twenty-second  year.  The 
Ronteen  ravs,  however,  enabled  the  writer  to  observe 
the  well-marked  cartilaginous  condition  of  the  lower 
tibial  epiphysis  and  a  distinct  epiphyseal  line  in  a 
healthy  man  of  twenty-four  years.  In  dwarfs  the  epi- 
physis may  remain  cartilaginous  up  to  the  fortieth  year. 

The  symptoms  are  the  same  as  those  of  the  cor- 
responding fractures  in  adults.  A  most  unpleasant 
feature  of  epiphyseal  separation  is  the  tendency  to 
premature  ossification,  which  leaves  a  stunted  limb. 

In  rickets  (an  infantile  disease  so  frequent  in  Europe, 
and,  thanks  to  its  prosperity,  very  rare  in  this  coun- 
try) the  bones  are  brittle,  in  spite  of  their  containing 
an  abundant  proportion  of  animal  matter;  so  they  are 
therefore  very  liable  to  break  in  consequence  of  even 
a  small  degree  of  violence.  The  greatest  tendency  to 
such  fracture  is  shown  by  the  clavicle  and  femur. 

Fragility  in  scurvy  and  in  infantile  paralysis  of  long 
standing  are  also  well  known.  From  clinical  observa- 
tion the  writer  has  received  the  impression  that  the 
presence  of  tuberculosis  of  the  knee-joint  also  predis- 
poses to  fragility  of  the  femur  in   childhood. 

It  is  but  natural  that  the  subjective  symptoms  of  frac- 
ture in  a  child  should  differ  somewhat  from  those  of 
analogous  injuries  in  adults.  Particularly  the  inability 
to  call  attention  to  pain  and  to  the  site  of  fracture  must 
be  considered  in  very  young  children.  The  author  has, 
for  instance,  observed  cases  of  infantile  supramalleolar 
fracture  where  objective  symptoms,  especially  displace- 
ment and  deformity,  were  absent,  while  the  subjective 
symptoms  present  pointed  toward  an  injury  of  the  hip- 
joint — a  mistake  which  was  cleared  up  only  after  dis- 


76  FRACTURES    IN    GENERAL. 

coloration  of  the  supramalleolar  integument  called 
attention  to  it.  It  must  also  be  borne  in  mind  that  in 
children  the  pain  of  a  fracture  is  less  intense  than  in 
adults,  and  that  in  many  cases  it  is  even  insignificant. 
(See  p.  8 1.)  If  non-ossified  tissues,  such  as  the  area  of 
an  epiphysis,  are  concerned,  or  if,  as  often  happens  in 
childhood,  the  periosteum  has  remained  intact,  other 
valuable  signs — displacement,  deformity,  and  crepitus 
— will  naturally  be  absent.  In  fact,  the  line  of  fracture 
in  some  cases  is  so  indistinct  that  it  is  difficult  to  fix 
it,  even  on  a  plate  made  by  the  Rontgen  rays.  (See 
Fig.  I37-)  The  deformity  caused  by  a  greenstick 
fracture  is  often  so  slight  that  it  may  easily  escape 
notice.  These  unpleasant  features  of  infantile  frac- 
tures are  somewhat  atoned  for  by  their  agreeable 
property  of  tending  in  most  cases  to  rapid  and  almost 
certain  union,  a  property  which  is  due  to  the  active 
formative  process  in  the  infantile  bone  and  to  the 
abundance  of  the  callus  production.  These  facts  ex- 
plain the  rare  occurrence  of  deformities  as  well  as  of 
non-union  in  childhood. 

Non-union  occasionally  occurs  in  fractures  sustained 
in  liter 0  or  shortly  after  birth,  and  especially  in  cases  of 
necrosis  of  the  humerus  and  the  tibia.  (See  Figs.  134, 
135.)  There  is  a  decided  influence  upon  the  trophic 
nerves  in  this  disturbance,  probably  due  to  a  subtle 
derangement  of  the  anterior  horn  of  the  spinal  cord, 
in  consequence  of  which  the  nutrition  of  the  bone  is 
inhibited.  Consequently  the  bone  is  rendered  weak 
and  friable  and  its  repair  is  hindered. 

The  principles  of  treatment  are  identical  with  those 
applying  for  adults.  Epiphyseal  separation  must  also 
be  treated  according  to  the  same  rules.      In   children 


PECULIARITIES    OF    FRACTURES    IN    CHILDREN.  J  J 

the  plaster-of-Paris  dressing  can  be  used  to  a  much 
greater  extent  than  in  adults.  (See  p.  34,  on  treat- 
ment.) As  to  detailed  rules,  see  Part  II,  on  Fractures 
of  Special  Regions. 


PART  II. 
FRACTURES  OF  SPECIAL  REGIONS, 


FRACTURES  OF  THE  SHOULDER  AND 
UPPER  EXTREMITY. 

CLAVICLE. 

Fracture  of  the  clavicle  comprises  sixteen  per  cent, 
of  all  fractures.  It  is  caused  either  by  direct  vio- 
lence— such  as  blows  and  falls — or  by  transmission 
of  the  impulse  of  a  fall  upon  the  shoulder  or  the 
extended  arm.  The  longitudinal  axis  of  this  bone, 
which  is  interposed  between  scapula  and  sternum  like 
a  buttress,  becomes  compressed  to  a  certain  extent, 
and  must  break  at  the  point  of  its  least  resistance. 
This  is  generally  located  between  its  medial  and  exter- 
nal   thirds,   the  bone  beine    least    in    diameter  there. 

7  O 

(Fig.  14.)  Fractures  of  the  sternal  and  acromial  ends 
are  rather  uncommon. 

While  rare  in  the  aged,  fracture  of  the  clavicle  is 
extremely  frequent  in  childhood.  The  character  of 
the  fracture  is  generally  simple.  In  children  infrac- 
tions are  also  frequently  met  with.  Sometimes  in  chil- 
dren the  sternal  extremity  is  torn  off. 

Symptoms. — The    symptoms    of    fracture    of    the 

78 


THE  PATHOLOGY  AND  TREAT- 
MENT OF  SEXUAL  IMPOTENCE. 
By  Victor  G.  Vecki, 
M.  D.  From  the 
second  German  edi- 
tion, revised  and  re- 


VECKTS 
SEXUAL 
IMPOTENCE 


written.  Handsome  Demi-Octavo  vol- 
ume of  nearly  300  pages.  Cloth,  $2.00 
net. 

JUST  ISSUED. 

Although  no  one  denies  that  the  sexual  function 
is  of  the  very  greatest  consequence  to  the  indi- 
vidual as  well  as  to  society  in  general,  yet  the 
subject  of  impotence  has  but  seldom  been  treated 
in  this  country  in  the  truly  scientific  spirit  that 
its  pre-eminent  importance  deserves,  and  this 
volume  will  come  to  many  as  a  revelation  of 
the  possibilities  of  therapeutics  in  this  important 
field.     The   author  ventures   to  assert   that   in 


"It  is  a  well-written,  scientific  work  .  .  .  carl  be 
recommended  as  a  scholarly  treatise  on  its  subject, 
and  it  can  be  read  with  advantage  by  many  practi- 
tioners."— Journal  of  the  American  Medical  Asso- 
ciation. 


many  cases  it  is  a  better  deed  to  restore  to  an 
impotent  man  the  power  so  precious  to  every 
individual,  than  to  preserve  a  dangerously  sick 
person  from  death,  for  in  many  cases  death  is 
preferable  to  impotence.  This  edition,  although 
based  on  the  German  edition,  has  been  entirely 
rewritten  by  the  author  in  English.     <£>    <£     <£ 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


PRACTICAL  POINTS  IN  NURS- 
ING* For  Nurses  in  Private  Practice. 
By  Emily  A.  M. 
Stoney,  Graduate  of 
the  Training  -  School 


STONEVS 
NURSING 


for  Nurses,  Lawrence,  Mass*;  Late 
Superintendent  of  the  Training-School 
for  Nurses,  Carney  Hospital,  South 
Boston,  Mass.  456  pages,  handsomely 
illustrated.    Cloth,  $1.75  net.    J>     J- 

SECOND  EDITION,  REVISED. 

The  author  explains,  in  popular  language,  the 
entire  range  of  private  nursing  as  distinguished 
from  hospital  nursing,  and  the  nurse  is  instructed 
how  to  meet  the  various  emergencies  that  arise. 
A  valuable  feature  of  the  -work  will  be  found  in 
the  directions  for  improvising  everything  ordi- 


"  There  are  few  books  intended  for  non-profes- 
sional readers  which  can  be  so  cordially  endorsed 
by  a  medical  journal  as  can  this  one." — Thera- 
peutic Gazette. 

"  A  work  that  the  physician  can  place  in  the 
hands  of  his  private  nurses  with  the  assurance  of 
benefit." — Ohio  Medical  Journal. 


narily  needed  in  the  sick-room.  The  Appendix 
contains  much  information  of  great  value  to  the 
nurse,  including  Rules  for  Feeding  the  Sick; 
Recipes  for  Invalid  Foods  and  Beverages ;  Dose- 
list  ;  and  a  complete  Glossary  of  Medical  Terms 
a.nd  Nursing  Treatment.  &  &   *£    v*    %S*    *£* 

For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


SHOULDER  AND  UPPER  EXTREMITY. 


79 


Fig.  14. — Fracture  of  tbe  left  clavicle. 


Fig-  15- — Fracture  of  the  clavicle.      Slight  axial  displacement  (after  Hoffa). 


So  FRACTURES    OF    SPECIAL    REGIONS. 

clavicle  are  typical.  The  sternal  end  of  the  clavicle  is 
elevated  by  the  action  of  the  sterno-cleido-mastoid 
muscle,  while  the  acromial  portion  is  pulled  down  by  the 
weight  of  the  arm  and  scapula.  Thus,  either  simply  an 
angle  (Figs.  15  and  16)  is  formed,  or  the  sternal  end  is 
overlapped  by  the  acromial,  the  displacement  so  elevat- 
ing the  fragment  that  the  deformity  becomes  rather 
conspicuous  even  from  simple  inspection.  The  clavicle 
having  ceased  to  be  the  buttress  between  shoulder  and 


Fig.  16. — Fracture  of  the  clavicle.      Union  after  four  weeks  (axial  displacement 

not  reduced). 

thorax,  the  shoulder  sinks  downward  and  inward.  The 
motions  of  the  arm,  especially  elevation  and  abduction, 
naturally  become  painful,  a  symptom  that  finds  its  illus- 
trative expression  by  the  patient  generally  supporting 
his  elbow  with  the  hand  of  the  uninjured  extremity. 
Instinctively  the  patient  turns  his  hand  toward  the 
affected  side  in  order  to  relax  the  sterno-cleido-mastoid 
muscle. 

Diagnosis. — A   simple  fracture  of  the  clavicle    is 
easily  recognized.      Inspection    reveals    displacement, 


SHOULDER    AND    UPPER    EXTREMITY.  51 

which  is  sometimes  considerable.  The  writer  has 
observed  cases  in  which  the  two  fragments  were  each 
directed  upward,  like  two  vertical  posts,  so  that  the 
tissues  were  forcibly  pressed  upward.  Thus  a  picture, 
not  unlike  that  of  a  tumor  of  the  neck  was  created. 
(Fig.  17.)  More  or  less  dyspnea,  which,  of  course, 
disappears  as   soon  as   reposition   is   effected,  is   also 


Fig.  17. — Fracture  of  the  clavicle,  showing  considerable  displacement,  the 
upper  fragment  riding  and  lifting  the  integument  forcibly  upward,  in  a  man  thirty 
years  of  age  (one  week  after  the  injury). 


present  in  these  cases.  It  there  is  a  clear  history, 
fracture  of  the  clavicle  is  seldom  overlooked;  but 
practical  experience  shows  that  it  often  happens  that 
infants  are  dropped  by  careless  nurses  or  mothers, 
and  that  the  crying  of  the  patients  is  attributed  to 
some  entirely  different  cause.  To  hide  the  careless- 
ness, a  misleading  report  is  sometimes  given.  Cases 
of   fracture  of   the  infantile    clavicle    are    not   rare  in 

6 


82 


FRACTURES    OF    SPECIAL    REGIONS. 


which  nothing-  but  an  inability  to  lift  the  arm  is 
noticed,  and  an  ointment  for  the  forearm  is  pre- 
scribed. Nothing  shows  the  necessity  of  making  it  a 
principle  always  to  denude  the  whole  body  in  children, 
whenever  there  is  the  slightest  suspicion  of  an  injury 


Fig.  1 8. — Deformity  caused  by  considerable  displacement  in  a  boy  of  ten  years. 


to  any  bone,  more  especially  since  this  oversight  may 
lead  to  most  unpleasant  consequences  to  the  attendant 
physician. 

The  swelling  on  the  point  of  fracture,  the  near  ap- 
proach of  the  injured  shoulder  to  the  sternum,  and  the 
characteristic  interruption  in  the  bone  line,  common 
here  as  in  all  fractures,  are  all  features  that  can  easily 
be  palpated,  and  are  all  unmistakable  symptoms. 

Displacement  is  naturally  absent  in  simple  infraction, 


SHOULDER  AND  UPPER  EXTREMITY.         83 

and  sometimes  also  in  real  fracture.  In  these  rare 
cases  it  is  the  local  pain  in  the  first  place  that  claims 
attention.  It  is  obvious  that,  the  signs  of  displacement 
lacking-,  such  conditions  are  often  overlooked.  A  mis- 
take of  this  kind  fortunately  does  not  amount  to  much 
practically,  since  such  cases  are  almost  sure  to  heal 
without  any  treatment.  (Fig.  16.)  Whenever  doubt 
exists,  the  Rontgen  rays  will  furnish  elucidation. 

Course. — Union  is  generally  perfect  in  three  weeks. 


Fig.  19. — Deformity  caused  by  considerable  displacement  in  the  case  illustrated 
by  figure  18.      Skiagram  taken  six  weeks  after  the  injury. 


Even  in  cases  of  extensive  displacement,  where  reduc- 
tion is  entirely  neglected,  union  is  to  be  expected.  It 
is  astonishing,  that  even  where  the  overlapping  of 
the  fraoqnents  causes  considerable  shortening  of  the 
clavicle,  the  function  of  the  shoulder  or  the  arm  is  but 
seldom  impaired.      (See  Figs.  18  and  19.) 

From  a  cosmetic  point  of  view  such  outcome  will 
certainly  be  condemned.  The  disfigurement  caused 
by  the  protrusion  of  the  skin  on  account  of  the  over- 


84 


FRACTURES    OF    SPECIAL    REGIONS. 


lapping  fragment  is  sometimes  great,  and  if  it  concerns 
a  female  patient,  the  deformity  will  be  liable  to  cause 
no  little  unhappiness.  (Figs.  20  and  21.)  It  is  remark- 
able, however,  that  sometimes  there  is  hardly  any  pro- 
trusion, in  spite  of  the  riding  of  the  very  much  dis- 
placed fragments.      If  there  be  such  callus  prolifera- 


Fig.  20. — Typical  fracture  of  the  clavicle  in  a  girl  of  eight  years.      Marked 
deformity,  caused  by  riding  of  upper  fragment. 


tion,  pressure  maybe  conveyed  to  the  brachial  plexus. 
Pseudarthrosis  is  extremely  rare  in  fractures  of  the 
clavicle. 

Treatment. — As  in  all  other  fractures,  prompt  re- 
position is  the  main  indication.  This  is  generally  done 
without  any  difficulty.  It  is  made  best  while  an  assis- 
tant stands  behind  the  patient,  who  sits  in  a  chair.    The 


SHOULDER    AND    UPPER    EXTREMITY.  85 

attendant  pulls  the  injured  shoulder  backward.  If 
reposition  is  imperfect,  more  force  may  have  to  be  ap- 
plied by  the  assistant  pressing  his  knee  against  the 
back  of  the  patient  while  reposition  is  tried.  Thus 
reposition  is  easy  ;  but  keeping-  the  fragments  well 
immobilized  is  a  much  more  difficult  matter.  Many 
kinds  of  appliances  have  been  devised  for  this  purpose, 
most  of  them  being  intended  to  raise  the  shoulder  and 
to  bring  it  back  and  outward,  so  as  to  counteract  the 


Fig.  21. — Fracture  of  the  clavicle  showing  riding  of  the   fragments.     Same  case 
as  figure  20.     Skiagram  taken  two  days  after  the  injury. 

displacing  causes.  These  demands  are  well  fulfilled 
by  Velpeaii  s  dressing,  which  is  applied  best  by  means 
of  a  long  roller  bandage.  After  a  small  pad  is  put 
into  the  axilla  of  the  injured  side,  the  arm  is  conducted 
over  the  anterior  thoracic  wall  and  the  hand  is  placed 
upon  the  uninjured  shoulder.  It  is  evident  that  this 
elevation  of  the  hand  pushes  the  injured  shoulder  as 
far  upward  as  possible,  while  the  adductor  of  the  arm 
pulls  the  acromial  end  outward.  The  bandage  is  car- 
ried obliquely  from  the  sound  axilla  over  the  injured 


86 


FRACTURES    OF    SPECIAL    REGIONS. 


shoulder  down  to  die  elbow,  whence  it  runs  up  to  the 
axilla  again,  and  so  forth. 

Sayre  s  dressing  (Fig.  22)  is  also  much  in  favor.  It 
demands  three  long,  wide,  adhesive  plaster  strips,  the 
first  one  of  them  bein^  attached  to  the  inner  surface  of 
the  upper  arm  of  the  injured  side  and  passing  around 
the  anterior  surface  of  the  arm  backward  over  the  back 
to  the  chest  wall.  (Fig.  22  a.)  This  procedure,  which 
rotates  the  upper  arm  outward,  prevents  the  clavicle 
from  riding  upward  and  pushes  the  elbow  portion  of 


Fig.  22. — Sayre's  dressing:  a,  First  strip  ;  />,  second  strip,  front  and  back  views. 


the  humerus  (and  thus  the  shoulder  also)  backward, 
upward,  and  outward  by  pressing  the  elbow  forward, 
downward,  and  inward.  The  second  strip  fortifies  the 
position  of  the  first  by  fastening  the  arm  and  hand  of 
the  injured  side  to  the  chest  wall.  (Fig.  22  b.)  The 
strip  starts  from  the  uninjured  shoulder,  and,  passing 
over  the  antibrachium  and  elbow  to  the  dorsum,  re- 
turns to  the  starting-point  on  the  shoulder  again. 
Now  the  fragments  must  be  accurately  adjusted  and 
the  deformity  will  necessarily  disappear.  The  third 
strip,  therefore,  serves  as  a  kind  of  a  mitella  only.      It 


SHOULDER    AND    UPPER    EXTREMITY. 


87 


surrounds  the  carpus  of  the  injured  side,  and  runs  to 
the  back  after  having-  passed  over  the  fractured  area. 
It,  however,  elevates  the  hand  somewhat  and  presses 
slightly  upon  the  fragments. 

The  Sayre  dressing,  while  most  ingenious,  does  not 
afford  so  firm  a  support  as  the  Velpeau  bandage  or 
the    author's.     Furthermore,  it   has    the  great   disad- 
vantage  that   the    adhesive 
plaster  often  creates  such  a 
dermatitis   that  in    summer 
time  it  can  not  be  tolerated. 

The  results  obtained  by 
the  author's  dressing  were 
just  as  good,  without  expos- 
ing the  patients  to  any  dis- 
comfort. Absolute  firmness 
is  warranted  by  employing 
a  moss  splint  that  immobi- 
lizes the  shoulder  as  well  as 
the  elbow.     (Fig.  23.) 

The  first  step  consists 
in  drawing-  the  shoulders 
backward,  while  pressing  the  thorax  (Fig.  24  a)  or 
the  knee  against  the  patient's  scapula.  Then  a  moss 
splint,  suitably  trimmed  for  proper  adaptation  (Fig. 
23),  is  applied  to  the  shoulder.  (Fig.  24  b.)  The 
elbow  portion  is  molded  and  folded  in  the  same  man- 
ner. If  slightly  dipped  into  lukewarm  water,  it  will 
adapt  itself  well  to  the  contour  of  the  shoulder. 

The  axilla  is  filled  out  with  a  pad  of  borated  gauze. 
The  hand  also  rests  on  a  thick  layer  of  borated  gauze 
at  the  anterior  thoracic  wall,  the  fingers  reaching  up 
to  the  sound  clavicle. 


Fig.    23. — Moss   splint,  trimmed   for 
author's  dressing.     (See  Fig.  24  b.) 


A  TEXT-BOOK  OF  EMBRYOL- 
OGY. By  John  C  Heisler,  M.D., 
Professor  of  Anat- 
omy in  the  Medico- 
Chirurgical  College, 


HEISLER'S 
EMBRYOLOGY 


Philadelphia.  Octavo  volume  of  405 
pages,  with  190  illustrations,  26  in 
colors.    Cloth,  $2.50  net. 

JUST  ISSUED. 

The  facts  of  embryology  having  acquired  in 
recent  years  such  great  interest  in  connection 
with  the  teaching  and  with  the  proper  compre- 
hension of  human  anatomy,  it  is  of  first  im- 
portance to  the  student  of  medicine  that  a  con- 
cise and  yet  sufficiently  full  text-book  upon  the 
subject  be  available.  It  was  with  the  aim  of 
presenting  such  a  book  that  this  volume  was 


"  The  book  is  written  to  fill  a  want  which  has  dis- 
tinctly existed  and  which  it  definitely  meets;  com- 
mendation greater  than  this  it  is  not  possible  to  give 
to  anything." — Medical  News,  New  York. 


written,  the  author,  in  his  experience  as  a 
teacher  of  anatomy,  having  been  impressed 
with  the  fact  that  students  were  seriously  handi- 
capped in  their  study  of  the  subject  of  embry- 
ology by  the  lack  of  a  text-book  full  enough  to 
be  intelligible,  and  yet  without  that  minuteness 
of  detail  which  characterizes  the  larger  treatises, 
and  which  so  often  serves  only  to  confuse  and 
discourage  the  beginner.       <£     jit     Jt     Jt     jt 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


A  MANUAL  OF  DISEASES  OF 
THE  EYE.  By  Edward  Jackson, 
A.M.,  M.D.,  for- 
merly Professor  of 
Diseases  of  the  Eye 
in  the  Philadelphia 


JACKSON  ON 
DISEASES  OF 
THE  EYE 


Polyclinic  and  College  for  Graduates 
in  Medicine.  J2mo,  604  pages,  with 
J  78  illustrations  from  drawings  by  the 
author.    Cloth,  $2.50  net. 

JUST  ISSUED. 

This  book  is  intended  to  meet  the  needs  of  the 
general  practitioner  of  medicine  and  the  begin- 
ner in  ophthalmology.  More  attention  is  given 
to  the  conditions  that  most  be  met  and  dealt 
with  early  in  ophthalmic  practice  than  to  the 
rarer  diseases  and  more  difficult  operations  that 
may  come  later.  <£  <£  *J*  S  <£  <£  S 
It  is  designed  to  furnish  efficient  aid  in  the 
actual  work  of  dealing  with  disease,  and  there- 
fore gives  the  place  of  first  importance  to  the 
recognition  and  management  of  the  conditions 
present  in  actual  clinical  work.  For  practitioners 
in  other  departments  of  medicine  and  surgery, 
the  most  important  phase  of  ophthalmology  is 
that  of  the  relations  of  ocular  symptoms  and 
lesions  to  general  diseases.  A  special  chapter 
is  devoted  to  these  relations,  and  the  references 
it  contains  will  put  the  reader  in  touch  with  the 
related  facts  in  all  the  preceding  chapters.  J*   J* 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


SHOULDER    AND    UPPER    EXTREMITY.  89 

Now  the  sunken  arm  is  elevated  by  passing-  a  roller 
bandage  under  the  elbow,  over  the  clavicular  area  of 
the  healthy  side.  Then  the  lower  third  of  the  humerus 
is  tightly  drawn  to  the  thorax  and  transversely  fixed 
by  a  turn  of  the  bandage.  Finally,  the  elbow  is  sup- 
ported by  another  turn  passing  over  the  injured  area. 
(Fig-.  24  c.)  In  children  this  dressing  should  be  pro- 
tected by  broad  strips  of  rubber  adhesive  plaster. 

The  author's  dressing  can  be  used  in  all  the  different 
types  of  clavicular  fracture,  but  has  proved  to  be  espe- 
cially useful  when  simultaneous  injuries  of  the  integu- 
ment exist.      (Compare  p.  66  on  moss  dressings.) 

SCAPULA. 

Fractures  of  the  scapula  are  rare,  comprising  only 
about  one  per  cent,  of  all  fractures.  They  concern 
either  its  spine,  body  (Fig.  25),  neck  (Fig.  26),  the 
acromion  (also  Fig.  25),  or  the  coracoid  pi'ocess. 

Fractures  of  the  spine  and  the  body  of  the 
scapula  are  either  simple  fissures  or  fractures  without 
any  displacement,  and  consequently  heal  under  almost 
any  treatment.  The  principal  signs  are  ecchymosis, 
crepitus,  and  pain.  A  correct  diagnosis  is  often  only 
possible  with  the  aid  of  the  Rontgen  rays. 

The  treatment  consists  in  immobilizing  the  arm  with 
a  splint,  which  surrounds  the  shoulder  and  passes  over 
the  scapula  to  the  spine. 

Fracture  of  the  neck  of  the  scapula  (Fig.  26) 
in  itself  is  extremely  rare.  It  occurs  more  frequently 
in  connection  with  a  fracture  of  the  floor  of  the 
glenoid  cavity.  The  severed  glenoid  cavity  sinking 
downward  and  inward,  the  shoulder  loses  its  convex 
shape  and  the  arm  appears  longer,  so  that  this  injury 


9° 


FRACTURES    OF    SPECIAL    REGIONS. 


is  very  liable  to  be  confounded  with  the  subcoracoid 
dislocation  of  the  humerus.  (Figs.  34,  35,  36.)  But  in 
this  fracture  the  arm  is  freely  movable  in  all  directions, 
while  in  dislocation  free  motion  is  arrested.  Further- 
more, the  convexity  of  the  shoulder  at  once  springs 
up  again  as  soon  as  the  humerus  is  pushed  upward 
and  outward,  while  in  the  case  of  dislocation  the  nor- 


Fig.  25. — Stellate  splinter  fracture  of  the  scapula. 


mal  contour  of  the  shoulder  appears  only  when  the 
reduction  has  been  made  perfect. 

The  treatment  consists  in  Velpeau's  or  the  author's 
dressing.  (See  p.  87.)  Union  is  generally  complete 
in  four  weeks. 

Fracture  of  the  acromion  (compare  Fig.  25)  is 
nearly  always  caused  by  direct  violence  (fall  or  blow). 
The    signs — generally  well  marked — are   ecchymosis, 


SHOULDER    AND    UPPER    EXTREMITY. 


91 


pain,  crepitus,  flattening,  and  sinking  downward  and 
inward.  Even  if  there  be  extensive  blood  extrava- 
sation, the   sharply   localized   pain    and    the    crepitus, 


Fig.  26. — Fracture  of  the  neck  of  the  scapula  (after  Hoffa). 


which  is  never  absent,  are  symptoms  too  characteris- 
tic to  permit  of  a  mistake. 

The  treatment  is  practically  the  same  as  that  of  frac- 
ture of  the  neck  of  the  scapula.  (See  p.  90.)  Union 
is    generally  perfect  in    about  three  weeks.      Even   it 


92  FRACTURES    OF    SPECIAL    REGIONS. 

there  be  fibrous  union  only,  there  is  no  functional  dis- 
turbance. 

Fracture  of  the  coracoid  process  is  rare  and  is 
also  generally  caused  by  direct  violence.  After  this 
fracture  the  short  head  of  the  biceps  muscle  and  the 
coracobrachialis  and  the  pectoralis  minor  muscles  pull 
the  coracoid  process  inward  and  downward.  The  dis- 
placement is  hardly  noticeable,  but  the  localized  pain, 
the  mobility  of  the  fragment,  and  the  disturbance  of 
the  function  of  the  arm  are  marked  symptoms. 

The  treatment  is  the  same  as  that  of  the  fracture  of 
the  neck  of  the  scapula. 


HUMERUS. 

Fractures  of  the  humerus  comprise  about  eight 
per  cent,  of  all  fractures.  They  are  best  classified 
according  to  their  seat,  as  fractures  of  the  upper  end, 
of  the  diaphysis,  and  of  the  lower  end.  All  the  dif- 
ferent varieties  of  fracture  of  the  humerus  also  occur 
in  children. 

Fractures  of  the  upper  end  of  the  humerus  are 
caused  either  by  direct  or  indirect  violence.  They  are 
subdivided  as  fractures  of  the  anatomic  and  surgical 
necks, — including  the  traumatic  epiphyseal  solution  of 
the  upper  end  of  the  humerus,  the  so-called  trans- 
tubercular  fracture, — and  fractures  of  the  tuberculum 
majus  and  minus. 

I.  Fracture  of  the  anatomic  neck  of  the  humerus 
(Fio-.  27)  is  caused  by  direct  violence,  especially  by 
a  fall  upon  the  outstretched  hand.  Like  the  intra- 
capsular fracture  of  the  femur,  it  is  an  intra-articular 
fracture.      It  is  especially  observed  in  aged  persons, 


A  TEXT-BOOK  OF  OBSTETRICS. 

By  Barton  Cooke  Hirst,  M.D.,  Pro- 
fessor of  Obstetrics 
in  the  University 
of      Pennsylvania. 


HIRST'S 
OBSTETRICS 


Handsome  octavo  volume  of  846 
pages.  6\&  illustrations  and  7  colored 
plates.  Cloth,  $5.00  net;  Half  Mo- 
rocco, $6.00  net.  J-  J>  J>  J>  J> 
SECOND  EDITION. 

This  work  is  intended  as  an  ideal  text-book  for 
the  student  no  less  than  an  advanced  treatise  for 
the  obstetrician  and  for  general  practitioners.  It 
represents  the  very  latest  teaching  in  the  practice 
of  obstetrics  by  a  man  of  extended  experience  and 
recognized  authority.  The  book  emphasizes 
especially,  as  a  work  on  obstetrics  should,  the 


"The  illustrations  are  numerous  and  are  works  of 
art,  many  of  them  appearing  for  the  first  time.  The 
arrangement' of  the  subject-matter,  the  foot-notes,  and 
index  are  beyond  criticism.  As  a  true  model  of  what 
a  modern  text-book  on  obstetrics  should  be,  we  feel 
justified  in  affirming  that  Dr.  Hirst's  book  is  without 
a  rival." — New  York  Medical  Record. 


practical  side  of  the  subject,  and  to  this  end  pre- 
sents an  unusually  large  collection  of  illustra- 
tions. Most  of  these  are  new,  and  the  collec- 
tion will  form  a  complete  atlas  of  obstetrical 
practice.  This  work  records  the  wide  experi- 
ence of  the  author,  which  fact,  combined  with 
the  brilliant  presentation  of  the  subject,  renders 
it  one  of  the  most  notable  bocks  on  obstetrics. 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price, 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


LECTURES  ON  THE  PRINCI- 
PLES OF  SURGERY.  By  Charles 
B.  Nancrede,  M.D.,  LL.D.,  Professor 
of    Surgery    and 


NANCREDE'S 
PRINCIPLES  OF 
SURGERY. 


of  Clinical  Sur- 
gery, University 
of  Michigan, 
Ann  Arbor;  Emeritus  Professor  of 
General  and  Orthopedic  Surgery,  Phi- 
ladelphia Polyclinic.  Octavo  volume 
of  about  350  pages,  handsomely  illus- 
trated with  original  drawings  and  pho- 
tographs.   Cloth,  $2.50  net.  J-   J>  jt 

JUST  ISSUED. 

Although  many  excellent  works  have  been 
written  treating  of  the  Principles  of  Surgery, 
the  attempt  to  render  them  too  comprehensive 
has  marred  their  usefulness  for  the  undergrad- 
uate. The  present  book  is  based  on  the  lectures 
delivered  by  Dr.  Nancrede  to  his  undergraduate 
classes,  and  is  intended  as  a  text-book  for  stu- 
dents and  a  practical  help  for  teachers.  By  the 
careful  elimination  of  unnecessary  details  of 
pathology,  bacteriology,  etc.,  which  are  amply 
provided  for  in  other  courses  of  study,  space  is 
gained  for  a  more  extended  consideration  of  the 
Principles  of  Surgery  in  themselves,  and  of  the 
application  of  these  principles  to  methods  of 
practice.    Jt<£<£<2*<£<£jtjtjt 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W".  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


SHOULDER  AND  UPPER  EXTREMITY 


93 


which  fact  is  well  explained  by  the  senile  atrophy  of 
the  bone  tissue. 

The  signs  are  abnormal  mobility,  crepitus,  loss  of 
function,  and  pain.  The  extracapsular  character  nat- 
urally prevents  palpation  of  the  second  fragment.  If 
the  tubercula,  together  with  the  diaphysis,  are  inwardly 
displaced,  the   shoulder  becomes   flattened   so   that   a 


Fig.  27. — a,   Exterior  appearance  ;   b,  fractured  head,  showing  slight  outward 
displacement  (after  Hoffa). 


deformity  similar  to  that  of  the  subcoracoid  dislocation 
is  created.  (Compare  Fig.  36.)  But  it  should  be  re- 
membered that  in  fracture  of  the  anatomic  neck  there 
is  much  more  shortening  of  the  arm  than  in  disloca- 
tion,  and  that  in  dislocation  free  motion  is  arrested. 
Even  in  the  case  of  impaction,  mobility  is  much  freer 
in  the  case  of  a  fracture  than  it  is  in  a  dislocation. 
So    far    as    the    possibility    of  confounding    this  type 


94  FRACTURES    OF    SPECIAL    REGIONS. 

with  the  fracture  of  the  scapular  neck  (Fig.  26)  is 
concerned,  in  which  the  arm  is  also  pushed  toward 
the  chest,  it  should  be  considered  that  in  fracture 
of  the  neck  of  the  humerus  (Fig.  33)  the  arm  is 
shortened,  while  in  fracture  of  the  neck  of  the 
scapula  it  is  elongated. 

If  impaction  be  present,  union  may  become  perfect  ; 
if  not,  the  severed  fragment  may  undergo  necrosis, 
since  it  would  receive  no  blood-supply.  Fortunately, 
this  fracture  type  is  not  absolutely  intracapsular  in 
most  cases ;  that  is  to  say,  the  fragment  is  not  severed 
in  its  whole  extent,  but  it  still  adheres  by  portions  of 
the  capsule,  so  that  the  vascular  supply  is  not  entirely 
cut  off.  Sometimes  callus  proliferation  is  so  abundant 
that  the  function  of  the  joint  is  inhibited.  (Figs.  29 
and  30.) 

The  treatment  consists  best  in  the  application  of  a 
well-padded  collar  splint,  which  extends  from  the  neck 
over  the  shoulder  and  the  extensor  portion  of  the  arm 
and  antibrachium  to  the  dorsum  of  the  hand.  Ex- 
tension by  weight  is  also  advised.  But  while  this 
method  of  treatment  is  excellent  as  far  as  the  final 
result  is  concerned,  it  has  the  disadvantage  of  confining 
the  patient  to  bed. 

II.  Fracture  of  the  surgical  neck  of  the  humerus 
occurs  much  more  frequently  than  fracture  of  the 
anatomic  neck,  and  is  generally  caused  by  direct 
violence  (fall  on  the  shoulder)  ;  sometimes  indirectly 
(fall  on  the  hand  or  elbow).  It  has  its  analogue  in  the 
extracapsular  fracture  of  the  neck  of  the  femur.  It  is 
common  in  all  ages.      (Figs.  31,  33.) 

Signs. — The  line  of  fracture  is  found  below  the 
tuberosities.     The  arm  is  shortened  more  than  in  frac- 


DISEASES  OF  THE  EYE.  A  Hand- 
book of  Ophthalmic  Practice.  By  G. 
E.  de  Schweinitz, 


De  SCHWEINITZ 
ON  DISEASES 
OF  THE  EYE 


M.D.,  Professor 
of  Ophthalmol- 
°gYt  Jefferson 
Medical  College,  Philadelphia;  Pro- 
fessor of  Diseases  of  the  Eye  in  the 
Philadelphia  Polyclinic  Octavo.  696 
pages,  illustrated.  Cloth,  $4.00  net; 
Sheep  or  Half    Morocco,   $5.00    net. 

THIRD  EDITION,  REVISED. 

The  book  has  been  thoroughly  revised  and 
much  new  matter  introduced.  Particular  atten- 
tion has  been  given  to  the  important  relations 


"  It  is  a  very  useful,  satisfactory,  and  safe  guide 
for  the  student  and  the  practitioner,  and  one  of 
the  best  works  of  this  scope  in  the  English  lan- 
guage."— Annals  of  Ophthalmology. 


which  micro-organisms  bear  to  ocular  disorders. 
A  number  of  special  paragraphs  on  new  subjects 


"  The  book  will  recommend  itself  by  its  thor- 
oughly practical  tone,  its  clearness  and  terseness 
of  language,  and  its  modernism." — New  York 
Aledical  Journal. 


have  been  introduced,  and  certain  articles,  in- 
cluding a  portion  of  the  chapter  on  Operations, 
have  been  largely  rewritten.   ^   ^   Jt   ^   J* 

For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


A   HANDBOOK    FOR    NURSES. 

By  J.  K.  Watson,  M.D.,  Edin.,  Assist- 
ant House=Surgeon, 
Sheffield  Royal  In- 
firmary and  Shef- 
field Royal  Hospi- 


WATSON'S 
HANDBOOK 
FOR  NURSES 


tal;  Late  House-Surgeon,  Essex  and 
Colchester  Hospital.  Crown  octavo, 
413  pages,  with  73  illustrations.  Cloth, 
$1.50  net.  J>     £•     J-     J-     &     J-     J> 

JUST  ISSUED. 

This  work  aims  to  supply  in  one  volume 
that  information  which  so  many  nurses  at  the 
present  time  are  trying  to  extract  from  various 
medical  works,  and  to  present  that  information 
in  a  suitable  form.  Nurses  must  necessarily 
acquire  a  certain  amount  of  medical  knowl- 
edge, and  the  author  of  this  book  has  aimed 
judiciously  to  cater  to  this  need  with  the  object 
of  directing  the  nurses'  pursuit  of  medical  infor- 
mation in  proper  and  legitimate  channels.  Jt  <£* 
The  book  represents  an  entirely  new  departure 
in  nursing  literature,  insomuch  as  it  contains 
useful  information  on  medical  and  surgical 
matters  hitherto  only  to  be  obtained  from  ex- 
pensive works  -written  expressly  for  medical 
men*  <^*     «*5*     %?&     &*     t£*     «£*     %£*     •£*     <^*     <^* 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

"w\  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


SHOULDER  AND  UPPER  EXTREMITY.         95 


Fig.  28. — Fracture  of  the  anatomic  neck  of  the  humerus,  showing  outward 
displacement  of  the  head  and  impaction  ;  girl  of  nine  years.  (One  week  after  the 
injury.) 


Fig.  29. — Fracture  of  the  anatomic  neck  of  the  humerus,  showing  outward 
displacement  of  head  and  abundant  callus  proliferation  in  a  man  of  sixty-four 
years  (three  weeks  after  the  injury). 


H 

Li 

1 

^H 

M 

| 

Fig-  3°- — Fracture  of  the  anatomic  neck  of  the  humerus,  showing  abundant 
callus  proliferation,  inhibiting  free  motion. 


Fig.  31. — Fracture  of  the  surgical  neck  of  the  humerus  (after  Hofla). 

96 


Fig.  32. — Ideal  union  in  fracture  of  the  surgical  neck  of  the  humerus,  show- 
ing perfect  apposition  and  normal  callus  formation,  in  a  boy  of  eight  years.  (Two 
weeks  after  the  injury.) 


Fie. 


-Fracture  of  surgical  neck  of  left  humerus.     Oute 


snowing  angular 


deformity  below  the  fracture,  and  ecchymosis  in  front  of  the  shoulder. 
7  97 


98  FRACTURES    OF    SPECIAL    REGIONS. 

ture  of  the  anatomic  neck.  The  lower  fragment  is 
pushed  inward,  the  pectoralis  major  and  latissimus 
dorsi  muscles  pulling  it  toward  the  thorax  ;  and  at  the 
same  time  it  is  drawn  upward  by  the  biceps,  triceps, 
and  coracobrachialis  muscles.  There  is  also  ecchy- 
mosis,  abnormal  mobility,  displacement,  and  generally 
crepitus.  As  to  displacement,  it  is  found  that  the  end 
of  the  diaphysis  may  be  directed  inward,  in  other  cases 
outward ;  the  latter  variety  being  by  far  the  rarer 
one.  In  case  of  inward  displacement  (Fig.  33)  tne 
arm  is  abducted  and  the  axis  of  the  arm  is  directed 
toward  the  clavicle  or  the  coracoid  process,  while  in 
outward  displacement  the  arm  is  kept  in  adduction. 
If  the  fracture  is  impacted,  it  may  be  confounded 
with  dislocation.  In  preglenoid  (subcoracoid)  disloca- 
tion (Figs.  34  and  35)  the  infraclavicular  fossa,  on 
account  of  the  projection  of  the  dislocated  head  of 
the  humerus,  appears  as  if  it  were  filled  up.  If  the 
surgeon  only  takes  the  trouble  of  palpating  this  pro- 
truding point,  he  will  receive  the  impression  of  the 
presence  of  a  hard  body  of  globular  shape,  which 
follows  all  motions  of  the  shaft  of  the  humerus.  Now, 
there  is  no  other  organ  in  this  region  that  could  be 
confounded  with  this  projection  represented  by  the 
dislocated  head  of  the  humerus.  Indeed,  the  flattening 
of  the  shoulder,  the  axial  change,  and  the  flat  promi- 
nence of  the  anterior  aspect  of  the  axillary  region 
should  be  sufficient  indications  of  the  presence  of  a  dis- 
location. And  if  there  be  a  subglenoid  (axillary)  dis- 
location (Fig.  36),  there  must  invariably  be  a  diastasis 
between  the  head  of  the  humerus  and  the  acromion, 
which  is  of  such  considerable  extent,  sometimes,  that 
the    fingers    can    be    introduced    into    the  gap.     The 


SHOULDER  AND  UPPER  EXTREMITY. 


99 


surgeon  should,  therefore,  always  try  to  insert  his 
hand  between  the  acromion  and  the  head  of  the 
humerus,  because  if  he  succeeds,  he  is  almost  sure 
to  have  a  dislocation  to  deal  with,  while  if  he  does 
not,  he  knows  that  the  head  of  the  humerus  is  at  its 
proper   place.     This  would  indicate   that  if  there  be 


Fig.  34. —  Preglenoid  dislocation  of  the  right  humerus  (front  view). 


false  motion,  a  fracture  must  be  assumed.  If  the 
arm  is  now  rotated,  while  the  head  is  steadied,  the 
latter  will  not  move.  Sometimes  the  rough  edges  of 
the  fragments  can  be  palpated,  if  the  axillary  portion 
is  firmly  grasped.  As  to  further  contradistinction 
from  dislocation  and    from  fracture    of  the  anatomic 


IOO 


FRACTURES    OF    SPECIAL    REGIONS. 


neck,  compare  page  93.  In  tumors  of  the  shoulder 
(Fig.  37),  in  inflammatory  (rheumatic)  and  tubercular 
processes,  it  happens  sometimes  that  if  a  history  of 
an  injury  is  given,  the  swelling  is  erroneously  taken 
for  callus  proliferation. 

Treatment. — Reposition  is  accomplished  by  pulling 


Fig.  35. — Preglenoicl  dislocation  of  the  right  humerus  (back  view). 


the  arm  downward  and  outward,  under  anesthesia,  if 
necessary.  Immobilization  is  attained  either  by  a 
collar  splint  (see  p.  45)  or  by  the  application  of  a 
plaster-of-Paris  dressing,  which  is  supported  by  coap- 
tation splints  around  the  fractured  area  and  its  imme- 
diate vicinity.     An  axillary  pad    should   be   employed 


SIKH  I.DEK    AND    UPPER    EXTREMITY. 


IOI 


and  the  forearm  should  be  kept  rectangularly  ban- 
daged. If  there  be  great  tendency  to  displacement,  as 
is  especially  found  in  oblique  fractures  of  the  surgical 
neck  of  the  humerus,  permanent  extension,  while  the 
patient  is  confined  to  bed,  should  be  preferred.  In 
a  week  the  patient  can  get  up,  after  which  extension  is 


Fig.  ^6. — Subglenoid  dislocation. 


employed  during  the  night  only,  the  patient  being  per- 
mitted by  day  to  walk  around  after  a  collar  splint  has 
been  applied.  (Fig.  8.)  As  shown  by  the  skiagram 
(Fig.  32),  excellent  results  can  be  obtained  by  this 
treatment. 

In  this  connection  the  traumatic  epiphyseal  separation 


102 


FRACTURES  OF  srECIAL  REGIONS. 


of  the  upper  end  of  the  humerus  must  also  be  mentioned, 
a  condition  frequently  observed  in  children  before  the 
process  of  ossification  in  the  epiphyseal  cartilage  is 
complete. 

The  signs  are  about  the  same  as  those  of  fracture 
of  the  surgical  neck  of  the  humerus,  except  that  the 


Fig-  37- — Osteosarcoma  developing  after  a  fall  upon  the  outstretched  hand,  and 
erroneously  taken  for  callus  proliferation.     (See  p.  ioo. ) 


crepitus  is  less  marked  on  account  of  the  soft  charac- 
ter of  the  friction  between  the  fractured  surfaces  (car- 
tilaginous crepitus). 

The  treatment  is  the  same  as  in  fracture  of  the  sur- 
gical neck.  It  is  sometimes  impossible  to  keep  the 
fragments  in  good  position,  or  even  to  reduce  them 
at  all.     When  reposition   is  impossible,  the  fragments 


SHOULDER  AND  UPPER  EXTREMITY. 


IO 


must  be  united  by  nailing  or  sewing  them  together. 
(See  p.  69.)  If  reposition  fails  to  be  perfect  in  chil- 
dren, further  growth  of  the  bone  is  arrested. 

III.  Transtubercular  fracture    (Fig.  38)    is  always  the 
result  of  direct  violence.     The  line  of  fracture  is  on  a 


Fig.  3S. — Transtubercular  fracture  caused  by  direct  violence,  in  a  man  of 
forty-five  years  (eight  weeks  after  the  injury),  leaving  considerable  functional  dis- 
turbance. 


level  with  the  tubercula,  and  its  direction  is  transverse. 
There  is  a  marked  depression  below  the  acromion. 
Crepitus  can  always  be  produced  by  rotating  the 
arm,   provided  there  is  no  impaction.      Displacement 


io4 


FRACTURES    OF    SPECIAL    REGIONS. 


is  nearly  always  present.  The  nature  of  this  injury 
generally  not  being  recognized  without  the  aid  of  the 
Rontgen  rays,  it  is  obvious  that  no  effort  is  made  to 
reduce  the  displaced  portion.      Consequently,  there  is 


Fig.  39. — Fracture  of  the  diaphysis  of  the  humerus,  showing  riding  ot 
fragments,  in  a  lad  of  fifteen  years.     (One  day  after  the  injury.) 


always  more  or  less  deformity  and  interference  with 
free  motion  in  the  joint. 

The  treatment  consists  in  proper  reposition  under 
the  control  of  the  Rontgen  rays,  and  the  after-treat- 
ment is  identical  with  that  for  fracture  of  the  neck  of 
the  humerus. 

IV.  Fracture  of  the  tuberculum  ma  jus  or  minus  is  al- 
ways accompanied  by  a  dislocation,  and   is  character- 


An  American  Text-Book  of  GENITO- 
URINARY DISEASES,  SYPHILIS, 
AND  DISEASES  OF  THE  SKIN. 

By  47  eminent 
Specialists. 
Edited  by  L. 
Bolton  Bangs, 
M.D.,  Con- 
sulting Sur- 
geon to  St. 
Luke's  Hospi- 


AMERICAN 

TEXT-BOOK  OF 

GENITO-URINARY 

DISEASES, 

SYPHILIS, 

AND  DISEASES 

OF  THE  SKIN 


tal  and  the  City  Hospital,  New  York; 
Professor  of  Genito-Urinary  Surgery, 
University  and  Bellevue  Hospital 
Medical  College,  New  York ;  and  W. 
A.  Hardaway,  A.M.,  M.D.,  Profes- 
sor of  Diseases  of  the  Skin  and  Syphi- 
lis in  the  Missouri  Medical  College, 
St.  Louis.  «3*     J>     J>     J>     J-     <£•     <£• 

JUST  ISSUED. 

Complete  in  one  imperial  octavo  vol- 
ume of  J  229  pages.  Illustrated  with 
over  300  engravings  and  20  full-page 
colored  plates.  Cloth,  $7.00  net ;  Sheep 
or  Half  Morocco,  $8.00  net.  J>  J-  J> 

Sent  post-paid  on  receipt  of  price. 

"W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


AN  AMERICAN  TEXT-BOOK  OF 
THE  DISEASES  OF  CHILDREN. 
By  65  Eminent 
Contributors. 
Edited  by  Louis 
Starr,  M.D., 
Consulting 


AMERICAN 
TEXT-BOOK  OF 
DISEASES  OF 
CHILDREN 


Paediatrist  to  the  Maternity  Hospital, 
Philadelphia.  Handsome  Imperial 
Octavo  Volume  of  \  244  pages,  pro- 
fusely illustrated.  Cloth,  $7.00  net; 
Sheep  or  Half  Morocco,  $8.00  net.    J> 

SECOND  EDITION,  REVISED. 

To  keep  up  with  the  rapid  advances  in  the  field 
of  pediatrics,  the  whole  subject-matter  embraced 
in  the  first  edition  has  been  carefully  revised,  new 
articles  added,  some  original  papers  amended, 
and  a  number  entirely  rewritten  and  brought  up 
to  date.  The  new  articles  include  "Modified 
Milk  and  Percentage  Milk-Mixtures/'  "Lithe- 
mia,"  and  a  section  on  **  Orthopedics."  Those 
rewritten  are  "Typhoid  Fever,"  "Rubella," 
"  Chicken-pox,"  "  Tuberculous  Meningitis," 
44  Hydrocephalus,"  and  **  Scurvy,"  while  exten- 
sive revision  has  been  made  in  "  Infant  Feed- 
ing," "Measles,"  " Diphtheria,"  and  "Cretin- 
ism." The  volume  has  thus  been  increased  in 
size  by  a  very  considerable  amount  of  fresh 
material.  i^^i^»»^'^^"»*»"^'«'" 


Send  post-paid  on  receipt  of  price. 
W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


SHOULDER    AND    UPPER    EXTREMITY.  105 

ized  by  pain,  functional  disturbance,   and  diastasis  of 
the  fractured  area. 

The  treatment  consists  of  relaxation  of  the  muscles 
that  are  inserted  at  the  tubercula  by  proper  rotation, 
and  of  immobilization  by  a  collar  splint. 

Fracture  of  the  diaphysis  of  the  humerus  is 
in  the  great  majority  of  cases  caused  by  direct  vio- 
lence, and  is  of  frequent  occurrence.  While  in  children 
(Fig.  39)  the  transverse  direction  is  predominant,  in 
adults  the  line  of  fracture  is  generally  oblique.  (Fig. 
40.)  As  a  rule,  there  is  but  little  displacement  in 
transverse  fractures  of  the  shaft,  while  in  oblique  frac- 
tures displacement  is  always  present.  It  is  then  either 
longitudinal  or  axial. 

The  signs  are  ecchymosis,  pain,  crepitus,  abnormal 
mobility,  and  loss  of  function,  besides  displacement.  In 
most  cases  union  becomes  perfect  in  from  five  to  six 
weeks. 

The  radial  nerve  may  experience  the  same  fate, 
since  its  situation  directly  on  the  periosteum  favors  its 
laceration  in  splintering  fractures.  The  same  nerve 
may  also  be  injured  by  overabundant  callus  prolifer- 
ation, so  that  it  becomes  tightly  embedded — in  fact,  in- 
carcerated— in  the  callus-tissue.  (See  Fig.  41.)  The 
consequences  of  this  condition  are  grave  disturb- 
ances in  the  sensory  as  well  as  in  the  motor  sphere. 
Protrusion  of  badly  united  fragments,  conveying  pres- 
sure upon  the  brachial  artery  or  vein,  produces  exten- 
sive edema  of  the  extremity.      (Fig.  40.) 

Treatment. — If  there  is  pronounced  tendency  to  dis- 
placement, a  collar  splint  (p.  45)  will  correct  the 
trouble.  Any  other  kind  of  splint  that  has  a  shoulder- 
cap  would  be  useful,  if  properly  applied.      In  applying 


106  FRACTURES    OF    SPECIAL    REGIONS. 

any  kind  of  dressings  great  care  should  be  taken  to 
avoid    pressure    on    the    axilla.      If   there  be   marked 


Fig.  40. — Double  fracture  of  the  diaphysis  of  the  humerus,  in  a  man  of  fifty 
years  (was  rickety  when  a  child),  two  months  after  the  injury.  Protruding  lower 
fragment,  causing  extensive  edema  of  arm  and  hand  by  pressure  upon  the 
brachial  vessels. 

tendency  to  displacement,  extension  by  a  heavy  weight, 
attached  to  an  adhesive  plaster  dressing,  should  be 
made  for  at  least  two  weeks. 


SHOULDER    AND    UPPER    EXTREMITY. 


IO; 


In  a  case  of  pressure-paralysis  of  the  radial  nerve, 
caused  by  callus  proliferation,  neurolysis,  as  described 
on  page  71,  should  be  performed.  In  most  of  the 
cases  where  the  incarceration  of  the  nerve  is  relieved 
by  chiseling  off  the  callus-tis- 
sue the  paralysis  disappears 
promptly. 

Pseudar  thro  sis  is  much  more 
frequently  observed  in  fracture 
of  the  humerus  than  in  that  of 
any  other  bone,  the  diaphysis 
preeminently  being  concerned. 
According  to  Gurlt,  thirty-four 
per  cent,  of  pseudarthroses 
affect  the  humerus.  This  de- 
plorable condition  is  always 
due  to  the  insufficient  coapta- 
tion of  the  fragments,  which 
generally  permits  the  interven- 
tion of  muscular  tissue.  Some- 
times true  new  joints,  contain- 
ing cartilage  and  synovia,  are 
formed,  as  described  in  pseud- 
arthrosis  of  the  tibia. 

In  cases  of  short  standing 
stretching-  the  elbow   and  the 

application  of  a  long  extension  splint,  reaching  from 
the  hand  to  the  shoulder,  may  be  employed.  Then, 
while  the  arm  hangs  down,  permanent  stretching  of 
the  fractured  area  is  accomplished.  In  most  cases, 
however,  subperiosteal  resection  followed  by  bone- 
suture  must  be  performed. 

Under  the  aegis  of  the  Rontgen  rays  pseudarthrosis 


Fig.  41. — Abundant  callus 
formation,  induced  by  lateral 
displacement  in  fracture  of  the 
lower  end  of  the  humerus,  and 
causing  pressure  on  radial  nerve. 


io8 


FRACTURES  OF  SPECIAL  REGIONS. 


of  the  humerus  has  become  unpardonable,  since  under 
their  guidance  any  slipping-out  of  the  fragments  can 
easily  be  noticed  and  corrected. 

Fractures  of  the  lower  end  of  the  humerus 
are  frequent  and  show  different  varieties,  the  cor- 
rect recognition  of  which  is  often  extremely  difficult, 
and  without  the  aid  of  the  Rontgen  rays  is  some- 
times impossible.     They  are   usually  caused  by  direct 

violence.  In  children  they 
are  nearly  invariably  the  re- 
sult of  falls.  Separation  of 
the  lower  epiphysis  in  child- 
hood is  sometimes  con- 
founded with  backward  dis- 
location of  the  radius  and 
ulna.  The  different  varieties 
are  best  classified  as  supra- 
condylar, diacondylar  (in- 
cluding epiphyseal  separa- 
tion), epi 'condylar,  and  inter- 
condylar (including  intra- 
articular separation  of  the 
capitulum  humeri). 

I.  Supracondylar  fracture 
(Figs.  42  and  43)  is  transverse  in  the  majority  of  cases, 
but  sometimes  its  line  is  oblique.  It  principally  occurs 
in  children  under  twelve  years  of  age — a  period  in 
which  the  locality  of  this  fracture  type  is  determined 
by  the  softness  of  the  bone-tissue.  This  explains  why 
in  children  a  fracture  nearly  always  results  from  a  fall 
upon  the  hand  or  elbow,  while  the  same  accident  gen- 
erally produces  a  dislocation  in  adults.  In  children 
this   type  is  sometimes  complicated  by  a  vertical  frac 


Fig.   42. — Exterior    view  of  supra 
condylar  fracture. 


SHOULDER    AND    UITER    EXTREMITY. 


IO9 


ture,  which  extends  into  the  joint,  so  that  the  so- 
called  T-fracture  results.  Supracondylar  fracture  has 
been  erroneously  described  by  some  authors  as  epi- 
physeal separation. 

The  signs  of  this  fracture  often  resemble  those  of 
the  backward  dislocation  of  the  antibrachium  (see 
Figs.  44  and  45),  there   being   three  main   signs  corn- 


Fig.  43. — Oblique  supracondylar  fracture  in  a  man  of  thirty-tive  years  (four 
days  after  the  injury). 


mon  to  both  injuries  :  namely,  shortening,  false  posi- 
tion, and  the  axial  direction.  There  is  always  a  back- 
ward displacement,  the  lower  fragment  being  pulled 
back  by  the  triceps  muscle.  (Fig.  42,  43.)  But  in  con- 
trast to  dislocation,  abnormal  mobility  and  crepitus 
are  always  present  in  fracture.  It  must  also  be  con- 
sidered that  flexion  at  a  rio-ht  anode  as  well  as  exten- 
sion    to   the    full  limit  is  always  possible  in   fracture. 


I  10 


FRACTURES    OF    SPECIAL    REGIONS. 


Another  striking  point  of  differentiation  is  the  return 
of  the  deformity,  whenever  reposition  has  been  made  ; 
while  in  dislocation  the  deformity  disappears  as  soon 
as  reposition  is  done.  A  further  pathognomonic  sign 
is  the  absence  of  the  projection  of  the  radial  head, 
which  in  a  case  of  dislocation  can  always  be  easily 
palpated.  The  olecranon  is  always  situated  higher 
in   dislocation  than   in   fracture.      In    cases   in  which  it 


Fig.  44. —  Backward  dislocation  of  the  elbow  (exterior  view). 


is  pushed  backward  together  with  the  transverse  epi- 
physeal line,  it  is  found  in  the  direction  of  that  line. 

To  give  a  resume,  it  should  be  considered  that  in 
dislocation  the  flexor  side  of  the  forearm  and  the 
extensor  side  of  the  upper  arm  appear  shortened,  the 
tendon  of  the  triceps  muscle  appearing  like  a  small 
arch,  the  concavity  of  which  is  directed  toward  the 
olecranon.  This  bone  portion  makes  itself  conspicuous 
then  as  a  marked  projection  posteriorly.     Thus,  two 


SHOULDER    AND    UPPER    EXTREMITY.  I  I  I 

lateral  grooves  are  formed.  It  will  also  be  found  that 
the  trochlea  can  be  palpated  in  front,  while  the  out- 
lines of  the  joint-surface  of  the  radial  head  can  be 
easily  grasped  in  the  back.  In  dislocation  the  trans- 
verse diameter  of  the  joint  always  remains  normal. 

The  diag7iosis  of  fracture  is  indisputable,  as  soon  as 
the  presence  of  false  motion  is  established.  This  is 
done  by  grasping  the  lower  fragment  on  its  projec- 


Fig.  45. — Backward  dislocation  of  the  elbow. 

tions,  the  epicondyles,  and  pushing  them  to  and  fro. 
Crepitus  is  also  never  absent  during  these  manipula- 
tions. In  T-fractures  the  prognosis  is  particularly 
grave  in  view  of  the  severe  complications  of  the 
joint. 

The  treatment  consists  in  reducing  the  fragment  by 
makine  extension  on  the  hand  and  antibrachium  under 
anesthesia,   if  necessary.      Whether  immobilization   is 


I  I  2  FRACTURES    OF    SPECIAL    REGIONS. 

better  kept  up  in  the  extended  or  in  the  flexed  posi- 
tion should  be  determined  by  the  ease  with  which  the 
fragments  can  be  kept  reduced  in  either  of  them.  In 
most  cases  the  decision  of  this  much-discussed  ques- 
tion should  be  left  to  the  surgical  instinct.  There  is 
no  doubt  that  the  rectangular  position  of  the  arm  is 
by  far  the  most  agreeable  for  the  patient  ;  but  it 
should  not  be  the  consideration  of  the  patient's  com- 
fort that  decides  the  position  in   so  important  an   in- 


Fig.  46. — Supracondylar  fracture,  showing  slight  backward  displacement,  in  a 
girl  often  years.      (Two  months  after  the  injury.) 

jury,  but  that  plan  should  be  adopted  that  assures  the 
securest  and  most  perfect  apposition. 

A  circular  plaster-of-Paris  dressing,  reaching  from 
the  shoulder  to  the  wrist,  is  preferred  by  the  author  lor 
immobilization.  In  most  cases  the  fragment  is  best 
reduced  and  retained  while  forcible  traction  is  made 
on  the  hand  by  an  assistant,  the  surgeon  or  another 
assistant  pushing  the  fragment  inward  with  the  left 
thumb.  During  this  manipulation  the  bandages  are 
applied.       If    after    a    week's    time     the     rectangular 


SHOULDER    AND    UPPER    EXTREMITY.  I  1 3 

position  is  gently  and  gradually  resumed,  the  ten- 
dency to  displacement  having  been  overcome,  the 
question  of  comfort  may  be  considered. 

More  than  in  any  other  fracture  type,  frequent  inspec- 
tion, control  by  the  Rontgen  rays,  and  eventual  change 
of  dressing"  is  indicated.  After  three  weeks,  active 
and  passive  motion,  together  with  massage  treatment, 
should  begin.  It  is  only  when  thorough  control  is 
practised  throughout  the  treatment  that  the  untoward 
outcome  of  varus  or  valgus  formation  is  certainly  pre- 
vented. 


Fig.  47. — Diacondylar  fracture,  causing  considerable  forward  displacement,  in  a 
boy  of  twelve  years  (outer  view). 

If  the  tendency  to  displacement  can  not  be  over- 
come, extension,  in  combination  with  a  wire  splint, 
should  be  used  for  two  weeks. 

The  radial  as  well  as  the  median  nerve  may  become 
lacerated  by  the  splintering  of  the  bone.  Whenever 
these  injuries  are  diagnosticated,  which  is  always  possi- 
ble under  the  auspices  of  the  rays  (compare  Fig.  41), 
neurorrhaphy  should  be  performed  without  delay. 
The  cubital  vessels  may  become  lacerated  in  the  same 
manner,  in  which  case  immediate  ligation  alone  can 
prevent  gangrene  of  the  arm. 

II.  Diacondylar  fracture  (fracture  of  the  cubital  pro- 


ii4 


FRACTURES    OF    SPECIAL    REGIONS. 


cess)  (Figs.  47  and  48)  is  caused  directly  by  a  fall  upon 
the  elbow  or  indirectly  by  a  fall  upon  the  hand,  and 
is  rather  rare.  It  always  extends  into  the  joint,  and 
is,  therefore,  in  fact,  an  intra-articular  fracture.  The 
line  of  fracture  is  transverse,  as  a  rule,  and  runs  along- 
side the  cartilaginous  joint-surface. 

The  treatment    must  be  conducted    after  the  same 
principles  as  that  of  the  supracondylar  fracture,  with 


Fig.  48. — Diacondylar  fracture  showing  displaced  fragment  attached  in 
oblique  direction,  thus  causing  a  resemblance  to  backward  dislocation  of  the 
forearm.      Skiagram  of  figure  47,  taken  six  weeks  after  the  injury. 


the  difference  that  motion  and  massage  must  begin  as 
early  as  one  week  after  the  injury  is  sustained. 

Epiphyseal  separation  in  children  must  be  considered 
under  the  same  view,  and  the  treatment  should  be 
conducted  after  the  same  principles  as  the  diacondylar 
fracture.  They  are  of  either  the  osseous  (Fig.  49)  or 
the  cartilaginous  (Fig.  50)  type. 


SIloULDER    AND    UPPER    EXTREMITY.  I  I  5 

III.  Epicondylar  fracture  is  far  more  frequent  than 
the  former  varieties.  It  is  caused  mainly  by  direct 
violence,  and  especially  by  a  fall  upon  one  or  the  other 
side  of  the  elbow  region.  It  is  either  oblique  and 
extends  into  the  joint  {intra-articular  epicondylar  frac- 
ture), or  extra- articular  and  concerns  the  epicondyle 
only  {isolated  epicondylar  fracture). 

The  intra-articular  epicondylar  fracture,  or  the  epi- 
condylar fracture  proper,  concerns  either  the  internal 
or   the    external    epicondyle,  and    its    line    is    always 


Fig.   49.  —  Osteo-epiphyseal  separation  of  lower  end  of  the  humerus  in  a  boy  of 
five  years,  showing  no  displacement  (one  day  after  the  injury). 

oblique.  The  internal  epicondyle  becomes  fractured 
if  the  fall  is  sustained  while  the  arm  is  abducted;  but 
the  external  epicondyle  is  fractured  while  the  arm  is 
in  adduction.  In  both  instances  the  line  of  fracture 
reaches  the  joint. 

The  fracture  of  the  internal  epicondyle  (Fig.  5 1 ), 
which  is  caused  by  a  fall  upon  the  middle  of  the  elbow, 
is  rarer  than  the  fracture  of  the  external  epicondyle. 

The  signs  are  slight  displacement,  crepitus,  abnor- 
mal mobility,  and  swelling  above   the  internal  epicon- 


u6 


FRACTURES    OF    SPECIAL    REGIONS. 


dylar  region,  the  latter  so  marked  that  this  area 
becomes  broader  and  more  prominent  than  is  natural. 
The  internal  epicondyle  is  more  pointed,  and  therefore 
responds  more  readily  to  palpation,  than  the  short  and 
blunt  external  epicondyle. 

The  treatment  consists  in  reducing  the  fragment  by 
pulling  and  by  retaining  it  properly  by  a  pad,  while 
the  forearm  is  in  flexion  ;  and  then  securing  with 
splints  or  a  plaster-of-Paris  dressing  in  a  rectangular 
position. 


Fig.  50. — Chondro-epiphyseal  separation  of  lower  end  of  humerus  in  a  girl 
of  two  years,  showing  considerable  displacement  of  fragment  (two  days  after  the 
injury). 


The  fracture  of  the  external  epicondyle  is  caused  by 
direct  violence  as  well  as  indirectly  by  a  fall  upon  the 
hand.  It  is  far  more  frequent  than  the  fracture  of  the 
internal  epicondyle. 

The  signs  consist  in  the  presence  of  an  extravasa- 
tion, abnormal  adduction  of  the  extended  forearm, 
disturbance  of  function,  pain  above  the  epicondyle, 
crepitus,  and  the  possibility  of  dislodging  the  fragment. 
The  latter  is  frequently  pulled  upward  by  the  biceps 
and  the   antibrachial    muscles,  which  fact   renders  its 


SHOULDER    AND    UPPER    EXTREMITY. 


117 


proper  retention  in  place  extremely  difficult.  It  fol- 
lows too  frequently  that  the  fragment  becomes  attached 
in  a  dislodged  position,  and  thus  it  sometimes  becomes 
an  obstacle  to  the  normal  motion  of  the  joint. 

The  treatment  of  the  fractured  external  epicondyle 
is  practically  the  same  as  that  of  its  internal  fellow. 
The  reduction  being  more  difficult,  anesthesia  is  more 
frequently  indicated  to  accomplish  this  purpose  thor- 
oughly. The  dressing  must  be  changed  every  few 
days.     After    the    elapse    of  two   weeks   motion  and 


51.— Intra-articular  fracture  of  the  internal  epicondyle  in  a  girl  of  thirteen 
years  ;  slight  displacement  backward  (two  days  after  the  injury). 


massaee  treatment  should  be  instituted.  If,  after  two 
weeks,  mobility  of  the  elbow  still  appears  to  be  arrested, 
it  is  advisable  to  use  wire  splints,  which  are  bent  to 
the  shape  of  the  elbow.  They  must  be  changed  every 
day,  in  order  to  permit  of  slight  motion.  This  is  done 
by  bending  the  elbow  each  day  a  little  more,  and 
accordingly  bending  the  wire  splint  to  the  altered 
shape  of  the  elbow.  If  the  fragment  can  not  be  thus 
retained  in  proper  position,  extension  by  weight  in  the 
longitudinal  direction  of  the  humerus  is  to  be  tried. 


n8 


FRACTURES    OF    SPECIAL    REGIONS. 


Isolated  epicondylar  fracture — that  is,  extra-articular 
fracture  of  either  the  internal  or  external  epicondyle 
(Figs.  52  and  53) — is  caused  by  direct  violence  (a  fall  or 
blow)  or,  more  frequently,  by  indirect  violence  (forci- 
ble abduction  of  the  arm). 

The  most  important  sign  is  the  displacement  and 
the  mobility  of  the  fragment.  There  is  also  circum- 
scribed extravasation.      Pain  is  absent  so  long  as  the 


Fig.  52.  —  Extra-articular  fracture  of  left  internal  epicondyle,  showing  consid- 
erable protrusion  of  the  epicondylar  fragment  and  irregular  callus  formation,  which 
inhibits  stretching  of  the  forearm,  in  a  man  of  thirty-two  years  (ten  weeks  after 
the  injury). 

arm  is  but  moderately  moved,  but  becomes  intense 
when  extension  and  flexion  are  carried  to  their  limits. 

The  treatment  is  practically  the  same  as  that  of  the 
intra-articular  type.  The  extra-articular  epicondylar 
type  is  sometimes  found  in  connection  with  outward 
and  inward  dislocation. 

IV.  Intercondylar  fracture  (Fig.  54)  is  of  a  severe 
character.      It  is  either  longitudinal  or  oblique.     In  the 


SHOULDER  AND  UPPER  EXTREMITY. 


II9 


latter  event  it  may  be  either  T-  or  Y-shaped.  The 
principal  sign  consists  in  the  possibility  of  moving  the 
fragments  to  and  fro  while  palpation  is  employed. 
These  types  are  often  combined  with  severe  injuries  of 
the  soft  tissues.  The  treatment  is  the  same  as  that  of 
the  supracondylar  variety.  (See  p.  108.)  In  rare 
cases  of  non-union  the  fragment  must  be  exposed  and 
fastened  to  the  surface  from  which  it  was  detached. 

In  addition,  intra-articular  separation  of  the  capitnlum 
humeri  (eminentia  capitata  humeri),  which  is  caused 


Fig.    53. — Extra-articular  epicondylar  fractures  (after  Hoffa). 

by  a  fall  upon  the  hand,  remains  yet  to  be  mentioned. 
In  this  injury  a  small  bone- fragment,  after  being  totally 
severed,  is  retained  as  a  free  body  in  the  joint.  It  is 
especially  observed  in  young  individuals. 

The  signs  of  this  rare  variety  are  slight  abduction  in 
the  joint  and  the  presence  of  an  intra-articular  exuda- 
tion. Extension  and  supination  are  extremely  painful. 
The  severed  fragment  can  generally  be  palpated  be- 
tween the  external  epicondyle  and  the  capitulum  radii. 
This  injury  may  be  confounded  with  the  fracture  of  the 
latter.     The  diagnosis  should  always  be  verified  by  the 


120 


FRACTURES    OF    SPECIAL    REGIONS. 


Rontgen  rays.     The  treatment  consists  in  the  excision 
of  the  severed  fragment. 

Irregular  callus  (Fig.  52)  is  frequently  produced  in 
the  different  varieties  of  fracture  of  the  lower  end  of  the 
humerus,  and  naturally  causes  considerable  functional 
disturbance  in  the  elbow-joint.  In  most  cases  it  is  due 
to  false   coaptation  of   small  bone-fragments.     When 


Fig.    54. — Longitudinal  intercondylar  fracture  in  a  boy  of  sixteen  years  ;   impossi- 
bility of  extension  (three  weeks  after  the  injury). 


several  bone-fragments  are  severed,  as  in  comminuted 
fractures,  blameless  restitutio  ad  integrum  can  be  ex- 
pected only  from  one  who  is  absolutely  ignorant  of 
the  anatomic  relations  of  the  elbow7.  Many  surgeons 
have  suffered  innocently  for  results  that,  under  the 
grave  circumstances,  were  in  reality  praiseworthy. 
But  unjust  patients  hold  different  views  sometimes. 
What  a  blessing  are  the  Rontgen  rays,  especially  in 


SHOULDER    AND    UPPER    EXTREMITY.  12  1 

the  treatment  of  this  injury,  which  even  under  the 
guidance  of  the  new  light  offers  the  greatest  difficulties 
for  proper  apposition  of  the  fragments!  Of  course,  in 
such  severe  cases  anesthesia  should  always  be  admin- 
istered during  reposition. 

If,  after  thorough  consolidation,  the  function  of  the 
elbow  is  prevented — as,  for  instance,  by  the  protrusion 
or  intervention  of  a  badly  united  bone-fragment  (Figs. 
48,  54),  or  by  the  interposition  of  the  olecranon  be- 
tween the  fragments — removal  of  the  cause  by  oste- 
otomy is  indicated.  The  arm  is  afterward  best  kept 
in  an  extension  dressing. 

In  oblique  supracondylar  fractures  oblique  coapta- 
tion often  takes  place,  so  that  after  consolidation  the 
axis  of  the  elbow-joint  also  becomes  oblique  accord- 
ingly. If  extended,  the  elbow  shows  an  angle  in  either 
the  interior  or  the  inner  direction,  as  the  case  may  be 
— cubitus  valgus  or  varus.  In  such  cases  a  perfect 
cure  can  be  obtained  only  by  severing  the  badly  united 
area  with  chisel  and  hammer. 

FOREARM. 

Fracture  of  the  forearm,  the  extremity  used  so  ex- 
tensively for  working,  as  well  as  for  protecting  the  body 
(this  member  being  instinctively  outstretched  when 
one  is  afraid  of  falling),  is  naturally  very  frequent. 

It  is  divided  into  fracture  of  the  : 

1.  Ulna  (olecranon,  coronoid  process,  diaphysis, 
styloid  process,  and  fissure  above  the  capitulum  ulnae). 

2.  Radius  (capitulum  and  collum  and  the  typical 
fracture  of  the  lower  end  of  the  radius). 

3.  Radius  and  ulna  together. 

Differentiation   from  dislocation  of  the  antibrachium 


122 


FRACTURES    OF    SPECIAL    REGIONS. 


is  of  great  importance.  Regarding  the  fact  that  there 
are  no  less  than  twelve  different  types  of  dislocation 
of  the  elbow,  the  difficulty  of  contradistinction  will  be 
appreciated. 

The  ulna  as  well  as  the  radius  can  be  dislocated 
simultaneously  toward  four  different  directions :  viz., 
outward  and  inward  as  well  as  forward  and  backward, 
the  latter  type  being  by  far  the  most  frequent.  Or  the 
ulna  is  dislocated  backward  while  the   radius  is  dislo- 


■•■ 


Fig.   55, — Fracture  of  the  olecranon.     Diastasis  caused  by  the  triceps  muscle 
pulling  the  upper  fragment  upward  (after  Hoffa). 


cated  forward  at  the  same  time.  The  ulna  may  also 
be  dislocated  backward,  while  the  radius  may  be  dislo- 
cated either  forward,  or  backward,  or  outward. 

I.  Ulna. — I.  Fracture  of  the  olecranon  is  nearly  always 
caused  by  direct  violence  (fall  on  a  stone  or  the  margin 
of  a  staircase,  or  the  like).  (Figs.  55  and  56.)  It  is  an 
exceptional  occurrence  when  simple  contraction  of  the 
triceps  muscle  produces  it.  According  to  surgical  text- 
books, fracture  of  the  olecranon  is  regarded  as  rare, 


SHOULDER  AND  UPPER  EXTREMITY. 


123 


and  it  is  judged  to  be  less  than  1  per  cent.  But 
the  author's  experience,  supported  by  the  Rontgen 
rays,  has  convinced  him  of  the  fallacy  of  this  view, 
which  is  sanctified  by  its  ancientness  only.  In  the 
author's  own  experience,  four  cases  of  fracture  of  the 
olecranon  process  were  discovered  by  skiagraphy 
among  the  material  of  his  surgical  clinics  during  a 
period  of  six  months  only.  These  cases  represented 
a   percentage  of  8   among  all  the  fractures  observed 


Fig.    56. — Fracture  of  the  olecranon.      Moderate  degree  of  diastasis  in  a  boy  ot 
fourteen  years  (four  days  after  the  injury). 


there  in  that  time.  Admitting  that  this  percentage 
was  in  part  accidental,  this  fresh  experience  cer- 
tainly points  to  a  percentage  higher  than  that  usually 
assumed. 

In  two  of  the  cases  the  author  was  not  sure  that  he 
had  to  deal  with  a  fracture  of  the  olecranon  until  he 
had  been  informed  by  the  aid  of  the  Rontgen  rays. 
It  must  naturally  be  seen  that  in  the  pre-Rontgenian 
era  surgeons  would  have  failed  to  register  such  cases 


124  FRACTURES    OF    SPECIAL    REGIONS. 

among  the  fractures  of  the  olecranon.  The  author's 
experience  furthermore  contradicts  the  widely  spread 
opinion  that  the  fracture  of  the  olecranon  does  not 
happen  before  the  fifteenth  year.  It  is  observed  from  the 
tenth  year,  when  the  nucleus  for  ossification  appears. 

The  fracture  is  almost  always  caused  by  direct  vio- 
lence upon  the  posterior  portion  of  the  elbow.  In  two 
cases  there  was  but  little  diastasis,  while  in  two  others 
it  was  considerable.  The  line  of  fracture  in  each  ot 
these  cases  was  transverse,  three  of  the  fractures  being 
of  the  simple  type  and  only  one  being  comminuted. 

Signs. — If  the  point  of  the  insertion  of  the  extensor 
muscles  of  the  forearm  is  severed  entirely,  active  ex- 
tension is  rendered  impossible.  The  triceps  muscle  pull- 
ing the  upper  fragment  upward,  more  or  less  diastasis 
is  produced.  (Fig.  55.)  Crepitus  is  seldom  absent. 
There  is  a  circumscribed  extravasation, — as  a  rule,  of 
a  globular  shape, — which  so  covers  the  line  of  frac- 
ture that  its  presence  may  not  always  be  readily  dis- 
covered. In  such  instances  it  is  only  by  deep  palpa- 
tion that  the  line  is  to  be  detected. 

If  the  fragments  are  still  kept  in  contact  by  the  peri- 
osteum little  or  no  diastasis  may  exist.  Consequently, 
there  will  be  no  crepitus.  It  is  especially  in  this  fortu- 
nate event  that  the  fracture  is  liable  to  be  overlooked. 
It  is  evident  that  such  cases  give  an  excellent  prognosis 
under  any  treatment.  But  if  there  is  diastasis,  bony 
union  may  remain  an  exception.  Still,  even  in  these 
examples,  if  the  fragments  remain  near  together  bony 
union  once  in  a  while  takes  place.  Usually,  however, 
fibrous  union  is  all  that  can  be  expected  ;  but  this  is 
generally  so  firm  that  in  the  majority  of  cases  the 
function  of  the  elbow  remains  but  little  impaired. 


A  Manual  of  MODERN  SURGERY. 

By  J.  Chalmers  Da  Costa,  M.D.,  Pro- 
fessor of  Practice  of 
Surgery  and  Clini- 
cal Surgery,  Jeffer- 


DA  COSTA'S 
SURGERY 


son  Medical  College,  Philadelphia; 
Surgeon  to  the  Philadelphia  Hospital, 
etc.  Handsome  octavo,  911  pages,  co- 
piously illustrated.  Cloth,  $4.00  net; 
Half  Morocco,  $5.00  net.      J-     &     & 

NEW  AND  ENLARGED  EDITION 

The  remarkable  success  attending  Da  Costa's 
Manual  of  Surgery,  and  the  general  favor  with 
which  it  has  been  received,  have  led  the  author 
in  this  revision  to  produce  a  complete  treatise 
on  modern  surgery  along  the  sam'e  lines  that 
made  the  former  edition  so  successful.    The 


Reviews  of  the  First  Edition. 

"  We  know  of  no  small  work  on  surgery  in  the 
English  language  which  so  well  fills  the  require- 
ments of  the  modern  student." — Medico-Chinir- 
gical  Journal,  Bristol,  England. 

"  Essentially  practical  in  its  scope,  judicious  in 
its  advice,  and  likely  to  prove  of  value  to  the 
student." — New  Yurk  Medical  Journal. 


book  has  been  entirely  rewritten  and  very  much 
enlarged.  The  old  edition  has  long  been  a 
favorite  not  only  with  students  and  teachers, 
but  also  with  practising  physicians  and  surgeons, 
and  it  is  believed  'hat  the  present  work  will  find 
an  even  wider  field  of  usefulness.   <£*   <£   <£   <£ 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


A  Manual  of  MODERN  SURGERY. 

By  J.  Chalmers  Da  Costa,  M.D.,  Pro- 
fessor of  Practice  of 
Surgery  and  Clini- 
cal Surgery,  Jeffer- 


DA  COSTA'S 
SURGERY 


son  Medical  College,  Philadelphia; 
Surgeon  to  the  Philadelphia  Hospital, 
etc.  Handsome  octavo,  9 \\  pages,  co- 
piously illustrated.  Cloth,  $4.00  net; 
Half  Morocco,  $5.00  net.     J-     J>     J> 

NEW  AND  ENLARGED  EDITION 

The  remarkable  success  attending  Da  Costa's 
Manual  of  Surgery,  and  the  general  favor  with 
which  it  has  been  received,  have  led  the  author 
in  this  revision  to  produce  a  complete  treatise 
on  modern  surgery  along  the  same  lines  that 
made  the  former  edition  so  successful.    The 


Reviews  of  the  First  Edition. 

"  We  know  of  no  small  work  on  surgery  in  the 
English  language  which  so  well  fills  the  require- 
ments of  the  modern  student." — Medico-Ckirnr- 
gical  Journal,  Bristol,  England. 

"  Essentially  practical  in  its  scope,  judicious  in 
its  advice,  and  likely  to  prove  of  value  to  the 
student." — New  York  Medical  Journal. 


book  has  been  entirely  rewritten  and  very  much 
enlarged.  The  old  edition  has  long  been  a 
favorite  not  only  with  students  and  teachers, 
but  also  with  practising  physicians  and  surgeons, 
and  it  is  believed  *  hat  the  present  work  will  find 
an  even  wider  field  of  usefulness.   «£*   <£*   <£*   •£ 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


SHOULDER    AND    UPPER    EXTREMITY.  I  25 

The  treatment  consists  in  the  application  of  a  plaster- 
of-Paris  splint  in  the  hyperextended  position  while 
the  displaced  fragment  is  tightly  grasped  and  pushed 
downward  by  the  fingers  of  an  assistant.  The  turns 
of  the  bandage  are  conducted  around  the  pressing 
fingers  in  such  a  manner  that  at  last  a  wall  is  formed 
around  the  digital  impressions,  which,  after  having 
become  dry,  so  holds  the  reduced  fragment  in  place 
that  return  of  the  piece  is  rendered  impossible.  (Com- 
pare Treatment  of  Fracture  of  the  Patella.) 

In  simple  cases  the  extension  dressing  can  be 
changed  into  the  rectangular  after  the  lapse  of  about 
two  weeks.  After  four  weeks  motion  and  massage 
must  be  employed.  In  the  event  of  considerable  ex- 
travasation, aspiratory  puncture  under  thorough  asep- 
tic precautions  is  advisable  before  reduction  is  at- 
tempted. If  all  these  points  are  carefully  observed, 
suturing  the  fragments  needs  to  be  resorted  to  only  in 
case  of  extreme  diastasis  and  in  compound  fractures 
of  the  olecranon.  The  technic  of  wiring  the  fragments 
is  essentially  the  same  as  in  fracture  of  the  patella. 

Separation  of  the  epiphysis  of  the  olecranon  is  rare, 
and  is  to  be  viewed  from  the  same  standpoint  as  the 
fracture.  It  should  be  remembered  that  the  epiphysis 
joins  the  diaphysis  in  the  seventeenth  year. 

II.  Fracture  of  the  coronoid  process  of  the  ulna  is  mostly 
caused  by  indirect  violence  (fall  on  the  outstretched 
hand  and  forearm).  It  represents  a  rare  type.  (Fig.  57.) 

The  signs  are  depression  at  the  olecranon,  so 
marked  that  the  ulna  appears  to  be  dislocated  back- 
ward. But  the  position  of  the  radius,  which  remained 
unchanged,  always  differentiates  the  fracture  from  the 
dislocation.    (Compare  Fig.  45.)    Further  signs  are  the 


126 


FRACTURES    OF    SPECIAL    REGIONS. 


intense  pain  felt  when  the  process  is  touched,  the 
crepitus,  and  the  impossibility  of  extending  the  fore- 
arm to  its  limit.  Palpation  of  the  fragment  is  gen- 
erally prevented  by  the  thickness  of  the  muscles  that 
run  over  the  fractured  area. 

This  fracture  type  is  sometimes  combined  with  back- 
ward dislocation  of  both  bones  of  the  forearm. 

The  treatment  consists  in  reposition  of  the  frag- 
ment, which  is  done  by  forcible  pulling  on  the  forearm. 
The  arm  then  is  flexed  at  an  acute  angle  and  immo- 


Fig-    57- — Fracture  of  the  coronoid  process  of  the  ulna  (after  1 1  off  a 


bilized  in  this  position  by  splints.  When  the  swell- 
ing has  subsided,  a  plaster-of-Paris  dressing  should  be 
applied.  After  the  lapse  of  two  weeks  the  position 
is  gradually  changed  until  extension  can  be  made. 
Passive  motion  and  massage  must  be  resorted  to  after 
three  weeks. 

In  most  cases,  on  account  of  the  diastasis  of  the 
fragments,  a  fibrous  union  is  all  that  can  be  looked 
for.  Still,  the  function  of  the  elbow  is  usually  but  little 
impaired  even  in  this  event.  When  there  is  an  abun- 
dant callus  proliferation,  the   function   of  the  joint   is 


SHOULDER  AND  UPPER  EXTREMITY. 


127 


apt  to  suffer.  In  such  cases  the  projecting  bone-mass 
must  be  chiseled  off. 

III.  Fracture  of  the  diaphysis  of  the  ulna  (Figs.  58  and 
59)  is  nearly  always  caused  by  direct  violence  (a  fall 
or  a  blow  warded  off  with  the  elevated  antibrachium). 
The  seat  of  the  fracture  is  generally  below  the  middle 
of  the  bone,  where  its  diameter  is  smallest  and  the 
bone  has  the  least  muscular  protection. 

The  signs  are  generally  well  marked,  since  the  ulna 
appears  to  be  folded  inward  at  the  point  of  fracture. 
There  is  ecchymosis,  local  pain,  abnormal  mobility, 
and  crepitus.     Usually,  there  is  also  an  extravasation 


Fig.    58. — Exterior  view  of  fracture  of  the  diaphysis  of  the  ulna. 


surrounding  the  seat  of  fracture.  Sometimes  the 
signs  are  insignificant,  as  in  the  case  illustrated  by 
figure  60. 

The  treatment  consists  in  the  adaptation  of  two 
splints,  reaching  from  the  wrist  to  the  elbow,  after 
reposition  has  been  accomplished  by  a  strong  pull. 
After  adjustment  and  dressing,  the  position  of  the  arm 
may  be  rectangular,  and  the  forearm  should  be  carried 
between  pronation  and  supination. 

In  cases  of  soft  callus  (Fig.  61),  sometimes  occurring 
in  childhood,  immobilization  must  be  kept  up  for  months. 
Sometimes  the  shaft  fractures  at  the  upper  third,  in 


123 


FRACTURES    OF    SPECIAL    RECIONS. 


which  case  it  was  taken  for  granted  that  this  injury  was 
always  combined  with  a  dislocation  of  the  capitulum 
radii.  But,  as  the  Rontgen  rays  show  in  figure  62,  such 
fractures  happen  without  injuring  the  radius.  As  will 
be  seen  later,  in  our  account  of  the  lower  end  of  the 
radius,  as  well  as  in  that  of  malleolar  fracture,  disloca- 


Fig.  59- — Fracture  of  ulnar  diaphysis,  showing  slight  displacement,  in  a  man 
fifty  years  of  age  (four  days  after  the  injury).  In  spite  of  the  inward  displace- 
ment, and  consequently  the  slight  anterior  bending  of  the  radius,  the  symptoms 
were  insignificant.  The  man  (truckman)  always  attended  to  his  heavy  work. 
The  moderate  pain  was  attributed  to  contusion,  and  therefore  no  immobilization 
had  been  attempted. 


tion  or  fracture  of  either  bone  of  the  forearm  generally 
follows  the  reception  of  any  amount  of  violence  strong 
enough  to  displace  the  fragments  of  its  broken  fellow. 
Therefore  it  was  a  priori  assumed  that  whenever  con- 
siderable displacement  in  ulnar  fractures  is  found,  either 
fracture  or  dislocation  of  the  radius  will  be  present  at 
the  same  time. 


SHOULDER    AND    UPPER    EXTREMITY. 


I29 


The  treatment  of  fracture  of  the  ulna  at  its  upper 
third  is  essentially  the  same  as  that  for  fracture  of  any 
other  portion  of  the  ulnar  diaphysis.  Particular  care, 
however,  should  be  taken  in  this  variety  to  exert  slight 
pressure  upon  the  capitulum  radii  by  applying  an  ad- 
hesive plaster  pad. 

If  the    displaced    fragment    is  pressed  against    the 


Fig.   60. — Well   united  fracture  of  diaphysis  of  the  ulna  in  a  woman  thirty-six 
years  of  age  (ten  days  after  the  injury). 


radius,  consolidation  may  take  place.  (Fig.  63.)  In 
this  event  supination  becomes  impossible.  At  an  early 
stage  reposition  under  anesthesia  may  be  successfully 
tried,  but  later  on  osteotomy  has  to  be  resorted  to. 

IV.  Isolated  fracture  of  the  styloid  process  of  the  ulna 
is  rare,  and  is  caused  by  direct  violence.    The  fragment 
9 


HO 


FRACTURES    OF    SPECIAL    REGIONS. 


can  always  be  distinctly  felt  underneath  the  integu- 
ment, and  since  it  can  easily  be  grasped,  its  proper 
reduction  can  always  be  accomplished.  To  retain  it 
well,  an  adhesive  plaster  pad  must  be  applied  over 
the  fractured  area.  The  dressing  must  immobilize  the 
elbow    as    well   as   the  wrist  for  at  least  two  weeks, 


Fig.   6l. — Fracture  of  the  lower  end  Fig.  62. — Fracture  of  the  diaphysis 

of  the  ulna  in  a  boy  of  twelve  years,  of  the  ulna.      Slight  displacement  in  a 

showing   soft    callus    formation     (three  child  of  two  years  (two  days  after  the 

weeks  after  the  injury).  injury). 


since  there  is  great  tendency  to  displacement — an 
event  that  might  be  followed  by  the  formation  of 
pseudarthrosis. 

Fracture  of  the  styloid  process  of  the  ulna  occurs,  in 
the  great  majority  of  cases,  in  connection  with  fracture 
of  the  lower  end  of  the  radius. 


SHOULDER    AND    UPPER    EXTREMITY.  131 

The  treatment  is  essentially  the  same  as  that  for 
fracture  of  the  lower  end  of  the  radius  combined  with 
fracture  of   the  styloid  process  of  the  ulna.      (See  p. 

154.) 

V.  Fissure  of  the  capitulum  ulnae  is  found  in  connec- 
tion with  the  classic  fracture  of  the  lower  end  of  the 


Fig.   63. — Fusion  of  radius  and  ulna  nine  weeks  after  fracture  of  the  ulna,  render- 
ing supination  impossible,  in  a  man  of  thirty-three  years.      (Compare  Fig.  69.) 

radius,  as  demonstrated  first  by  the  author.:i:  (Fig.  85.) 
This  phenomenon  was  never  recognized  until  the  Ront- 
gen  rays  taught  its  presence.  In  the  author's  cases 
the  line  of  infraction  has  always  been  transverse. 

*  See   "  The    Rontgen    Rays    in    Surgery,"   "  International    Medical 
Magazine,"  May,  1897. 


[  32 


FRACTURES    OF    SPECIAL    REGIONS. 


The  symptoms  of  its  presence  are  so  insignificant 
that  it  can  be  well  understood  why  in  former  times  no 
attention  was  ever  paid  to  it. 

2.  Radius. — I.  Fracture  of  the  head  of  the  radius 
(Figs.  64  and  65)  is  generally  caused  by  indirect 
violence  (fall  upon  the  outstretched  hand  when  in 
pronation).  Direct  violence  (blow  upon  the  head  of 
the  radius)  produces  it  but  exceptionally.     Sometimes 


Fig.  64. — Fracture  of  the  head  of  the  radius  in  a  man  thirty-two  years  of 
age  ;  skiagram  taken  through  plaster-of- Paris  wire  splint  twelve  hours  after  the  in- 
jury. There  was  considerable  outward  displacement,  which  was  believed  to  have 
been  reduced  after  the  dressing  was  applied,  but  the  skiagram,  taken  after  the 
dressing  was  completed,  showed  that  displacement  was  still  present.  (Compare 
Fig.  65.) 

there  is  only  an  infraction,  in  which  case  the  diagnosis 
could  not  be  made  without  the  aid  of  the  Rontgen 
rays.  Contusion  or  distortion  is  usually  suspected  in 
such  cases.  Its  character  is  naturally  intra-articular. 
It  is,  like  the  fracture  of  the  radial  neck,  observed 
as  an  isolated  fracture  as  well  as  in  combination  with 
one  of  the  other  bony  elements  of  the  elbow. 

If  there  is  a  complete  fracture,  abnormal  mobility  is 
always  present,  and  there  is  also  intense  pain  at  the 


GRIFFITH 
ON  THE 
BABY 


THE  CARE  OF  THE  BABY.    By 

J.  P.  Crozer  Griffith,  M.D.,  Clinical 
Professor  of  Diseases  of 
Children,  University  of 
Pennsylvania ;  Physi- 
cian to  the   Children's 

Hospital,  Philadelphia,  etc.     Octavo. 

404  pages.     Illustrated.    Cloth,  $1.50. 

SECOND  EDITION,  REVISED. 

The  author  has  endeavored  to  furnish  a  reliable 
guide  for  mothers  anxious  to  inform  themselves 
with  regard  to  the  best  way  of  caring  for  their 


"The  best  book  for  the  use  of  the  young 
mother  with  which  we  are  acquainted.  There 
are  very  few  general  practitioners  who  could  not 
read  the  work  through  with  advantage." 

— Archives  of  Pediatrics. 


children  in  sickness  and  in  health.  He  has 
made  his  statements  plain  and  easily  understood, 
in  the  hope  that  the  volume  may  be  of  service 


"  The  whole  book  is  characterized  by  rare 
good  sense,  and  is  evidently  written  by  a  master 
hand.  It  can  be  read  with  benefit  not  only  by 
mothers  but  by  medical  students  and  by  any 
practitioners  who  have  not  had  large  opportuni- 
ties for  observing  children." — American  Journal 
of  Obstetrics. 


not  only  to  mot'.ers  and  nurses  but  also  to  med- 
ical students  and  to  practitioners  whose  oppor- 
tunities for  observing  children  have  been  limited. 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


NERVOUS  AND  MENTAL  DIS- 
EASES. By  Archibald  Church,  M.D., 
Professor  of 
Clinical  Neu- 
rology, Mental 
Diseases,  and 
Medical  Juris- 


CHURCH  AND 
PETERSON'S 
NERVOUS  AND 
MENTAL  DISEASES 


prudence,  Northwestern  University ; 
and  Frederick  Peterson,  M.D.,  Chief  of 
Clinic,  Nervous  Department,  College 
of  Physicians  and  Surgeons,  New  York. 
Handsome  octavo,  843  pages,  with  over 
300  illustrations.  Cloth,  $5.00  net; 
Half  Morocco,  $6.00  net. 

SECOND   EDITION. 

This  book  is  intended  to  furnish  students  and 
practitioners  with  a  practical,  working  knowl- 
edge of  nervous  and  mental  diseases.  Written 
by  men  of  wide  experience  and  authority,  it 
will  present  the  many  recent  additions  to  the 
subject.  The  book  is  not  filled  with  an  ex- 
tended dissertation  on  anatomy  and  pathology, 
but,  treating  these  points  in  connection  with 
special  conditions,  it  lays  particular  stress  on 
methods  of  examination,  diagnosis,  and  treat- 
ment. In  this  respect  the  work  is  unusually 
complete  and  valuable,  laying  down  the  defi- 
nite courses  of  procedure  which  the  authors 
have  found  the  most  generally  satisfactory. 


J 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


SHOULDER    AND    UPPER    EXTREMITY.  1 33 

seat  of  the  fracture.      Crepitus  is  perceived  by  turning 
the  hand  alternately  in  pronation  and  supination. 

The  treatment  consists  in  the  application  of  an 
immobilizing  dressing  in  the  position  of  extreme 
flexion,  in  order  to  relax  the  biceps  muscle,  a  pad 
being  attached  over  the  fractured  area.  Immobili- 
zation must  be  kept  up  for  at  least  three  weeks,  in 
order  to  avoid  the  recurrence  of  displacement.  Pre- 
mature  contraction  of  the  biceps  muscle  might  sep- 


Fig.  65. — Fracture  of  the  head  of  the  radius.    Same  case  as  that  shown  in  figure  64. 
Displacement  corrected  in  the  extended  position  (four  days  after  the  injury). 


arate  the  replaced  fragments.  If  the  fragments  should 
not  be  properly  retained  in  place,  the  production  of 
extensive  adhesions  might  demand  resection  of  the 
radial  head. 

Sometimes  small  fragments  separated  from  the  car- 
tilage remain  detached,  and  act  like  foreign  bodies,  so 
as  to  disturb  the  function  of  the  elbow.  In  such  cases 
their  removal  may  be  indicated.  In  the  rare  event  of 
laceration  of  the  radial  nerve,  neurorrhaphy  is  indicated. 


134  FRACTURES    OF    SPECIAL    REGIONS. 

Epiphyseal  separation  occurs  in  infants  and  young 
children  in  a  small  number  of  cases.  It  is  caused  by 
holding  their  hands  up  or  by  swinging  them.  The 
treatment  is  the  same  as  that  of  fracture  of  the  radial 
head. 

II.  Fracture   of   the  neck  of    the    radius   is    still   rarer 


fig,  66. — Fracture  of  the  neck  of  the  radius  in  a  man  thirty  years  of  age. 
Moderate  deformity,  but  small  longitudinal  splinter  adhering  to  the  lateral  sur- 
face by  fibrous  tissue,  causing  functional  disturbance  (nine  years  after  the  injury). 

than  that  of  its  head.  Its  etiology  is  the  same.  The 
signs  are  also  similar,  the  only  difference  consisting 
in  the  impossibility  of  turning  the  radial  head  to  and 
fro  during  pronation  and  supination  in  cases  of  frac- 
ture of  the  neck.  A  bony  projection  may  also  be 
found  in  the  latter  event. 


SHOULDER   AND    UPPER    EXTREMITY.  1 35 

The  treatment  is  the  same  as  that  of  the  fracture 
of  the  radial  head. 

The  radial  nerve  may  become  lacerated  by  a  splinter 
of  bone  (Fig.  66),  in  which  case  removal  of  the  splinter, 
under  the  use  of  the  Rontgen  rays,  is  indicated. 

The  same  nerve  may  become  embedded  in  a  callus- 
mass  (Fig.  67),  in  which  event  it  must  be  freed  by 
chiseling  off  the  abundant  callus. 

III.  Fracture  of  the  shaft  of  the  radius  (Fig.  68)  is 
caused  by  violence,  either  direct  (blow  upon  the  arm) 
or  indirect  (fall  on  the  hand).     It  is  rare. 

The  signs  consist  in  displacement,  abnormal  mobility, 


Fig.  67. — Radial  nerve  thickened  and  embedded  in  callus-tissue  (after  Oilier). 

and  localized  pain.     Crepitus  is  perceived  whenever 
pronation  and  supination  are  exercised. 

The  treatment  consists  in  thorough  reposition  and 
the  application  of  an  upper  and  a  lower  splint  in  supi- 
nation. Immobilization  should  be  extended  over  the 
elbow  as  well  as  the  wrist.  If  reposition  is  imperfect, 
the  interosseal  space  may  be  filled  up  by  callus  forma- 
tion, and  a  consequent  fusion  with  the  ulna  would 
occur,  which  would  render  pronation  and  supination 
impossible.  (Fig.  69  ;  compare  Fig.  63  as  counter- 
part.) In  such  event  separation  by  operative  interfer- 
ence would  be  indicated. 


J 


6  FRACTURES    OF    SPECIAL    REGIONS. 


IV.  Typical  fracture  of  the  lower  end  of  the  radius  (erro- 
neously called  Colles'  fracture)  is  the  most  frequent 
fracture  type,  and  is  supposed  to  form  at  least  eighteen 


Fig.  68. — Fracture  of  the  shaft  of  the  radius  without  displacement  in  a  woman 
twenty-eight  years  of  age.  Slight  callus  formation  (seventeen  days  after  the 
injury) ;  also  showing  signs  of  well-united  fracture  of  the  lower  end  of  the  radius, 
sustained  six  years  earlier. 


Fig.  69. — Fracture  of  the  shaft  of  the  radius  in  a  man  thirty-six  years  of  age, 
showing  considerable  displacement,  the  upper  fragment  riding  upon  the  lower, 
thereby  causing  functional  disturbance  (one  year  after  the  injury). 

per  cent,  of  all  fractures.  In  the  author's  estimation  it 
figures  with  twenty-two  per  cent.  It  is  caused  by  a 
fall  upon  the  hand  while  in  dorsal  extension.  The 
very  strong  ligamentum  carpi  volare  profundum  being 


SHOULDER    AND    UPPER    EXTREMITY 


Si 


more  resistant  than  the  spongious  end  of  the  bone,  it 
is  evident  why,  as  first  demonstrated  by  Nelaton  (Fig. 
70),  that  structure  never  breaks,  and  that  a  radial 
fracture  can  be  the  only  result. 

In  no  fracture  type  have  the  Rontgen  rays  disclosed 
so  many  errors  as  in   this  much-disputed  fracture.     It 
can  safely  be  maintained  that  in  most  cases  skiagraphy 
has    revealed    conditions   that 
were    not    expected  and  that 
have  required  the  original  di- 
agnosis to    be    more    or   less 
modified. 

The  question  most  frequent- 
ly asked  of  a  surgeon  :  "  How 
do  you  treat  Colles'  fracture?  " 
or  "  Do  you  use  long  or  short 
splints  ?  Do  you  prefer  the 
plaster-of- Paris  dressing  or 
splint,  or  are  you  fond  of  Dum- 
reicher's,  Roser's,  Schede's, 
Braatz's,  Gordon's,  Kolliker's, 
Moore's,  Carr's,  Bond's,  Mid- 
deldorpf's  bilateral,  or  the  old 
pistol  splint  of  Nelaton  ?  Are 
you  in  favor  of  immobiliza- 
tion or  of  early  motion  ?  "  etc.,  show  that  fracture  of 
the  lower  end  of  the  radius  is  reearded  as  of  a  con- 
stant  type,  uniformly  characterized  by  the  fracture  of 
the  bone  about  an  inch  above  the  articulation,  and  fol- 
lowed by  a  silver-fork-shaped  deformity  of  the  wrist. 
This  point  of  view  is  inadequate  and  erroneous. 

It  has    been   found    that    the    anatomic    aspects    of 
the  various  forms  of  fracture  of  the  lower  end  of  the 


Fig.  70.  —  Fracture  of  the 
lower  end  of  the  radius  and  of 
the  styloid  process  of  the  ulna. 
The  ligamentum  carpi  volare  is 
much  strained,  but  is  still  coher- 
ing. 


138 


FRACTURES    OF    SPECIAL    REGIONS. 


radius  differ  in  fact  more  than  those  of  any  other  frac- 
ture; and  it  is  self-evident  that  such  variants  are  by  no 
means  of  indifferent  importance  in  respect  to  treat- 
ment. For  a  simple  fracture,  for  instance,  and  for  a 
Y-shaped  intra-articular  fracture,  different  therapeutic 
means  must  necessarily  be  sought.  Again,  the  vary- 
ing relations  of  the  fracture  of  the  radius  to  its  fellow, 
the  ulna,  are  of  great  practical  importance. 

Since  March,  1896,  when  the  author  first  began 
to  skiagraph  all  his  cases  of  fracture  and  suspected 
fracture,  until  recently,  he  has  observed  fracture  of  the 


Fig.  71. — Chondro-epiphyseal  separation  in  an  infant. 


lower  end  of  the  radius  sixty-two  times.  In  a  num- 
ber of  cases  fissure  of  the  ulna  coexists,  as  was  first 
reported  by  him.  Another  surprising  feature  is  that 
simultaneous  fracture  of  the  styloid  process  of  the 
ulna  has  been  found  in  a  great  number  of  cases,  a 
complication  that  was  formerly  supposed  to  be  of 
extremely  rare  occurrence. 

It  is  but  natural  that  our  views  should  be  changed 
by  fuller  clinical  experience  and  anatomic  observation. 
Without  undervaluing  the  great  work  of  our  surgical 
masters  before  the  Rontgen  era,  the  rays  furnish  the 


SHOULDER    AND    UPPER    EXTREMITY.  1 39 

most  convincing  proof  of  the  necessity  of  modifying 
their  interpretations  of  this  injury.  Thus,  having 
regard  to  old  experience  as  well  as  to  information 
gained  but  recently,  the  author  has  tried  to  classify 
those  different  forms  of  this  much-disputed  fracture 
that  appear  to  be  most  characteristic,  and  must  ac- 
cordingly demand  different  therapeutic  measures ; 
and  if  we  bear  in  mind  the  frequency  of  fractures  of 
this  type,  the  importance  of  the  discussion  will  be 
evident. 

In  classifying  the  different  varieties  of  fracture  of  the 
lower  end  of  the  radius  it  is  essential  to  distinguish  : 

(a)  Epiphyseal  separation. 

(6)  Fissures  (infractions). 

(c)  Complete  fractures. 

(d)  Incomplete  fractures. 

(e)  Fractures  of  the  lower  end  of  the  radius  com- 
bined with  infraction  or  fracture  of  the  head  of  the 
ulna. 

{/)  Fractures  of  the  lower  end  of  the  radius  com- 
bined with  fractures  of  the  styloid  process  of  the  ulna. 

All  these  different  varieties  may  be  extra-articular 
as  well  as  intra-articular. 

(a)  Epiphyseal  separation  of  the  lower  end  of  the 
radius  shows  the  same  symptoms  and  has  to  be  treated 
on   the  same  principles  as  the  complete  fracture. 

The  bicycle  enthusiasm  is  responsible  for  a  greater 
frequency  of  the  separation  of  the  lower  epiphyses  in 
young  adults. 

In  very  young  children  there  are  real  chondro- 
epiphyseal  separations  (Fig.  71),  in  which  the  epiphyseal 
cartilage  is  sharply  severed  from  the  osseous  end  of 
the  diaphysis  ;  while  later,  at  the  age  of  between  four- 


140 


FRACTURES    OF    SPECIAL    REGIONS. 


u 

u 

— 

2 

~ 

_& 

R 

V 

oj 

CJ 

H 

H 

CJ 

>. 

6 

CI 

CJ 

p 

cj 

Bi 

bJO 

p 

0 

— 

CJ 

a 

"3 

> 

£ 

,C 

0 
in 

CJ 

0 

CJ 

CJ 

?. 

— 

-r 

Bj 

OS 

V 

3 

c 

5. 

t/) 

c^ 

OS 

s 

£ 

«-> 

^^ 

CI 

CJ 

c 

bfl 

US 

u 

u 

> 

CJ 

5 

5/. 

11 

'H 

p 

0 

KS 

H 

5j 

03 

>b 

E 

3 

M 

sj 

d 

r^ 

7^ 

OS 

0H 

CJ 

p 

eS 

i- 

a; 

a! 

"c3 

-r 

cj 

— 

-3 

CJ 

OS 

}-t 

^g 

0 

CJ 

O 

;:/ 

es 

Oh 

0 

CJ 

ej 

,Q 

S 

u> 

OJ 

cd 

CJ 

0 

0 

-r 

OJ 

VI 

U 
CJ 

'c 

? 

0 

ns 

c^ 

? 

a 

CJ 

5, 

w 

c/i 

js 

>- 

CJ 

CJ 

CJ 

0 

oj 

: 

0 

M 

os 

J3 

OJ 

ss 

a 

,— 

p 

u 

c 

^ 

-z 

'w 

~ 

q 

<*H 

"5 

a 

•"5 

H 

O 

u 

5 

5 

:7 

si 
i-l 

0 

CJ 

0 

CJ 

OS 

CJ 

> 

si 

-r 

CJ 

<<-, 

£ 

p 

c 

CJ 
t/1 

0 

c_ 

_>■. 

^o 

pi 

cu 

t/i 

OJ 

~ 

1^ 

ij 

ni 

bJO 

0 

6 

u 

Kl 

Oh 

CJ 

E 

rT 

0 

CJ 
en 

.2 

0 

si 

CJ 

SHOULDER  AND  UPPER  EXTREMITY. 


I4I 


teen  and  seventeen,  osteo-epiphyseal  separation  is  ob- 
served, the  fracture-line  not  being  strictly  limited  to  the 
epiphyseal  cartilage,  but  extending  to  the  diaphysis. 
The  latter  variety  occurs  more  frequently  than  the 
first  one,  which  is  extremely  rare.  (See  Fig.  72,  right 
hand.)  There  is  a  great  tendency  to  rapid  union  in 
children.  Sometimes,  however,  the  growth  of  the 
radius  becomes  arrested,  notwithstanding  the  accom- 
plishment of  a  perfect  union. 


Fig-  73- — Eissure  of  the  lower  end 
of  the  radius,  one  inch  above  the  epi- 
physeal cartilage,  in  a  boy  fourteen 
years  of  age  (one  week  after  the  in- 
jury). 


Fig.  74. — Fissufe  of  the  lower  end  of 
the  radius  in  a  man  thirty-four  years  of 
age.  Small  splinter  protruding  toward 
the  ulna  (eight  hours  after  the  injury). 


(b)  Fissures  {infractions')  (Figs.  j$,  74)  are  extra-artic- 
ular as  well  as  intra-articular,  and  are  far  more  frequent 
than  was  supposed  before  the  discovery  of  the  Ront- 
gen  rays.  In  former  times  fissure  has  doubtless 
been  often  treated  as  distortion  or  contusion,  espe- 
cially when  only  small  splinters  were  broken  off.  (Fig. 
74).  No  displacement  being  present,  it  is  easily  un- 
derstood why  such  injuries  often  healed  under  any 
treatment.  Sometimes  these  cases,  not  being  rec- 
ognized in  their  true  light,  gave  a   better  prognosis 


14-  FRACTURES    OF    SPECIAL    REGIONS. 

than  those  which  were  properly  diagnosticated,  but  in 
which  the  limb  had  been  immobilized  during-  too  loner 
a  period. 

The  line  of  infraction  in  these  cases  is  either  trans- 
verse (as  in  Fig.  J3)  or  longitudinal  (Fig.  74),  so  that 
the  bone  appears  as  if  divided  into  halves  ;  or  it  is 
irregular  in  shape,  generally  resembling  a  star.  In 
such  cases  the  bone  is  divided  into  several  still  coher- 
ing portions. 

The  signs  are  severe  pain  and  slight  swelling  at  the 
seat  of  infraction.  Abnormal  mobility  and  crepitus 
being  absent,  the  diagnosis  of  contusion  or  distortion 
is  obviously  often  made. 

Treatment. — No  displacement  being  present,  no  re- 
duction is  required.  This  explains  why  the  results  in 
these  cases  are  nearly  always  good,  no  matter  what 
sort  of  treatment  is  employed.  In  fact,  if  they  are 
treated  by  a  quack,  whose  ignorance  leads  him  to  treat 
the  injury  as  a  sprain,  with  an  ointment,  a  poultice,  or 
"faith,"  a  better  result  may  sometimes  be  obtained 
than  by  the  learned  surgical  neophyte,  who,  after  a 
most  erudite  diagnosis,  immobilizes  the  joint  for  a  long 
period  in  his  zeal  to  keep  the  imaginary  fragments 
together.  Of  course,  no  deformity  will  result,  but 
adhesions  may  form  in  the  neighboring  joint  or  in  the 
sheaths  of  the  tendons,  and  the  wrist  may  become  stiff 
and  immobile.  In  such  a  case  a  patient  who  was  not 
treated  at  all — in  other  words,  whose  hand  was  not 
immobilized,  so  that  he  could  constantly  use  it — would, 
in  fact,  escape  unpleasant  consequences. 

In  cases  in  which  the  Rontgen  rays  prove  the  exis- 
tence of  a  fissure  beyond  a  doubt,  a  wire  splint  which 
is    slightly   bent  downward   is    to   be   applied  at  the 


SHOULDER    AND    UPPER    EXTREMITY.  1 43 

flexor  side  of  the  arm,  where  it  reaches  from  the  tip 
of  the  fingers  to  the  elbow,  the  downward  bent  portion 
of  the  splint  being  attached  to  the  palm  of  the  hand.  If 
there  is  much  swelling,  the  dressing  must  be  kept  moist 
with  Burow's  solution.      (Compare  pp.  48  and  67.) 

After  three  or  four  days,  when  the  swelling  has  sub- 
sided, this  long  splint  must  be  removed,  and  a  bracelet, 
consisting  of  a  piece  of  moss-board,  is  applied  instead. 
The  width  of  this  bracelet  should  be  about  four  inches, 
its  middle  corresponding  to  the  wrist.  This  appliance 
immobilizes  the  wrist  sufficiently,  and  at  the  same  time 
it  permits  enough  motion  to  counteract  the  formation 
of  adhesions  in  the  sheaths  of  the  tendons.  The 
patient  carries  his  hand  in  a  sling  in  such  a  manner 
that  the  ulnar  margin  rests  on  it.  Thus,  free  motion 
of  the  hand  is  permitted.  The  patient  is  told  to  move 
his  fingers,  as  in  playing  the  piano.  The  author  also 
finds  it  very  useful  to  advise  the  patient  to  grasp  mar- 
bles of  moderate  size  and  to  roll  them  around  in  the 
palm  of  the  hand.  Patients  generally  are  willing  to 
keep  these  marbles  in  their  pockets  and  play  with 
them  while  reading  or  conversing  or  walking  around. 
If  motion  is  thus  kept  up  constantly,  massage  treat- 
ment as  well  as  forcible  motion  can  be  dispensed  with 
in  this  fracture  type. 

(c)  Complete  fractures,  the  most  frequent  varieties 
of  fractures  of  the  lower  end  of  the  radius,  must  also  be 
subdivided  into  intra-articular  and  extra-articular. 

The  intra-articular  variety  is  the  most  important, 
since  it  is  always  complicated  with  more  or  less 
grave  injuries  to  the  joint-surfaces.  (Fig.  75.)  The 
line  of  fracture  is  generally  oblique,  but  sometimes 
nearly  longitudinal.     The    tendency    to   displacement 


144 


FRACTURES    OF    SPECIAL    REGIONS. 


is  particularly  marked  in  this  form.  Still,  abnormal 
mobility,  and  crepitus  accordingly,  are  but  seldom 
noticeable.  Since  there  is  generally  a  well-marked 
extravasation,  which  may  extend  even  over  the  sheaths 


Fig.  75. — Complete  intraarticular  fracture  (Y-shaped)  of  the  lower  end  of 
the  radius,  in  a  woman  of  forty  years,  showing  lateral  as  well  as  median  displace- 
ment of  fragments  (two  hours  after  the  injury). 

of  the  tendons,  palpation  is  rendered  extremely  diffi- 
cult and  uncertain.  Massage  has  to  be  employed 
early,  in  order  to  remove  the  extravasation,  when 
sometimes  the  margins  of  the  severed  fragments  can 
be  grasped.     Further  valuable  signs  of  fracture,  like 


SHOULDER    AND    UPPER    EXTREMITY.  1 45 

deformity,  caused  by  the  displacement,  may  also  be 
veiled  on  account  of  the  extravasation.  It  goes  with- 
out saying  that  another  sign  of  fracture,  severe  local 
pain,  is  never  absent. 

From  a  consideration  of  all  these  points  it  becomes 
evident  that  a  detailed  diagnosis  of  this  type  is  pos- 
sible only  by  the  aid  of  the  Rontgen  rays,  which  show 
us,  also,  just  how  the  displaced  fragments  are  to  be 
reduced.  Sometimes  reduction  can  be  done  prop- 
erly only  when  an  anesthetic  is  employed.  Forcible 
extension  for  the  purpose  is  contraindicated  because  it 
would  increase  the  traumatic  synovitis  always  present 
in  this  variety.  The  severed  fragments  are  readjusted 
best  by  gentle  grasping  manipulations.  An  adhesive 
plaster  pad  is  applied  over  the  displaced  fragment 
after  reduction  is  accomplished,  and  moderate  pressure 
until  slight  agglutination  has  taken  place.  This  may 
be  expected  after  a  few  days.  Then  further  pressure 
can  be  dispensed  with.  Otherwise  the  treatment  is 
the  same  as  that  of  the  extra-articular  variety.  (See 
p.  148.) 

Among  all  the  different  types  of  fractures  of  the 
lower  end  of  the  radius  the  intra-articular  is  the  most 
serious.  Only  the  continuous  control,  by  the  aid  of  the 
Rontgen  rays,  of  the  proper  situation  of  the  fragments 
will  give  good  results. 

The  extra-artictdar  complete  type  is  the  best  known 
among  the  varieties  of  this  fracture.  (Fig.  76.)  Having 
been  first  described  by  Colles,  it  is  called  Colles'  frac- 
ture in  this  country  as  well  as  in  England.  It  is  gen- 
erally transverse,  and  so  has  the  character  of  a  supra- 
condyloid  fracture.  Its  seat  is  generally  about  ^  of 
an    inch    above    the    articulation,   where    the  compact 


A. 


Fig.  76. — Extra-articular  fracture  of  the  lower  end  of  the  radius  (Colles' 
fracture)  in  a  young  man  of  twenty  years.  A.  Showing  inward  displacement  and 
impaction  (twelve  days  after  the  injury).  B.  Displacement  reduced  (three  weeks 
after  the  injury). 


fig.  77- — Complete  extra  articular  fracture  of  the  radius  (Colles'  fracture),  show- 
ing bayonet  shaped  deformity  (anterior  view). 
146 


SHOULDER    AND    UPPER    EXTREMITY. 


147 


tissue  of  the  cliaphysis  passes  over  into  the  cancellated 
spongiosa. 

Signs. — Displacement  always  being  present  in  this 
type,  the  deformity  is  highly  characteristic.  In  most 
cases  the  direction  of  the  displacement  is  upward,  so 
that  there  is  a  dorsal  promi- 
nence. In  such  cases  the  shape 
of  the  deformed  wrist  resem- 
bles that  of  a  bayonet  or  a  fork, 
for  which  reason  Colles'  fracture 
has  also  been  called  silver-fork 
fracture  {displacement  a  la  four- 
chette).  (Figs,  yy,  78.)  By  thus 
being  upwardly  dislodged,  the 
epiphyseal  portion  is  brought 
into  slight  supination,  while  the 
diaphysis  is  in  decided  prona- 
tion. The  epiphysis  being  in 
very  close  connection  with  the 
ulna,  the  latter  is  slightly  pushed 
toward  the  ulna  if  the  ligamentous 
connection  between  the  radial 
fragment  and  the  ulna  remains 
intact.  This  phenomenon  finds 
its  conspicuous  expression  in  the 
lateral  prominence  of  the  styloid 
process  of  the  ulna. 

Sometimes  the  tendency  of 
epiphyseal  displacement  is  toward  the  opposite  side 
or  downward,  and  the  deformity  appears  accordingly 
in  that  direction.  (Compare  Figs.  79,  80,  81.)  In  the 
first  case  the  direction  of  the  displacement  was  never 
recognized  in  the  pre-R6ntgen  era.    Abnormal  mobility 


Fig.  78. — Complete  extra- 
articular fracture  of  the  lower 
end  of  the  radius  (Colles' 
fracture)  showing  bayonet- 
shaped  deformity  (posterior 
view). 


148 


FRACTURES    OF    SPECIAL    REGIONS. 


is  always  present  to  a  greater  or  lesser  extent,  and 
consequently  there  is  always  crepitus. 

In  examining  the  patient  a  firm  support  must  be  ob- 
tained for  the  injured  hand,  the  latter  being  kept  down 
on  a  plane  by  an  assistant,  and  the  epiphyseal  frag- 
ment being  grasped.  Inspection  invariably  detects  the 
characteristic  abnormal  prominence,  while  palpation  is 


Fig-  79- — Downward  displacement  in  extra-articular  fracture  of  lower  end  of 
the  radius  in  a  man  thirty  years  of  age  (two  days  after  the  injury).  A.  Anterior 
view.      B.    Lateral  view. 


often  able  to  outline  the  shape  of  the  fragment.  The 
local  pain  is  generally  severe. 

In  the  rare  event  of  impaction  of  the  epiphyseal  end 
into  the  upper  end  of  the  radius,  abnormal  mobility 
and  crepitus  are  absent. 

Treatment. — The  first  requirement,  accurate  reduc- 
tion, may  be  carried  out  with  little  difficulty  by  forced 
extension,  the  hand  being  grasped  as  in  a  firm  hand- 
shaking,  with   downward   pressure    by   the    surgeon's 


SHOULDER    AND    UPPER    EXTREMITY. 


149 


thumb,  while  counterextension  is  used  on  the  forearm, 
which  is  flexed  rectangularly.  If  an  assistant  is  at 
hand,  the  surgeon  grasps  four  fingers  with  his  left,  and 


Fig.  80. — Extra-articular 
fracture  of  the  lower  end  of 
the  radius  in  a  woman  forty- 
five  years  of  age,  showing 
sideward  displacement  (one 
day'after  the  injury). 


Fig.  Si. — Extra  articular  fracture  of  the  lower 
end  of  the  radius  in  a  woman  forty-five  years  of 
age.  Skiagram  of  same  case  as  figure  80,  showing 
fragment  displaced  toward  the  ulna,  thus  causing 
the  slight  projection. 


the  thumb  with  his  right,  hand,  while  the  assistant  uses 
counterpressure  at  the  elbow.  (Fig.  83.)  If  this  pro- 
cedure should  fail,  anesthesia  must  be  employed. 


15° 


FRACTURES    OF    SPECIAL    REGIONS. 


Keeping  the  fragments  well  adjusted  in  a  proper 
position  is  quite  difficult  sometimes.  The  author  has, 
however,  always  been  able  to  secure  this  by  very  simple 
methods.  A  long  adaptable  wire 
splint  (see  p.  97)  is  applied  while 
forced  traction  is  made  ;  the  splint 
reaches  at  the  flexor  side  of  the  arm 
from  the  tip  of  the  fingers  to  the 
elbow.  If  the  direction  of  the  dis- 
placement is  upward  (silver-fork 
shape),  a  pad  of  adhesive  plaster  is 
attached  to  the  dorsal  integument 
above  the  fragment.  Then  a  short, 
narrow  splint  of  wood  is  applied 
on  the  dorsal  aspect  of  the  arm, 
reaching  from  the  metacarpopha- 
langeal joint  to  four  inches  above 
the  wrist,  and  is  kept  pressing  down 
by  the  application  of  a  gauze  ban- 
dage. 

If  the  tendency  of  the  displace- 
ment is  downward  (Fig.  79),  the 
same  procedure  is  carried  out  in 
the  opposite  manner,  the  wire  splint 
being  applied  on  the  dorsal  and  the 
wooden  splint  and  pad  on  the 
palmar  side  of  the  arm. 

If  the  displacement  be  sidewise 
(Figs.  80,  8 1 ),  which  is  most  marked 
when  there  is  a  simultaneous  injury 
of  the  ulna,  the  immobilization  must  be  carried  out 
on  entirely  different  lines.  The  adhesive  plaster  pad 
must  then  be  applied  laterally  to   the  fragment,   two 


Fig.  82. — Extra-articu- 
lar fracture  of  the  lower 
end  of  the  radius  in  a 
woman  forty-five  years  of 
age.  Immobilization  in 
plaster-of-Paris  dressing 
after  the  reposition  of  the 
displacement. 


SHOULDER    AND   UPPER    EXTREMITY. 


J5i 


long,  narrow  wooden  splints  being  used  at  the  same 
time.  One  of  these  splints,  being  a  little  broader  than 
the  diameter  of  the  bone,  begins  at  the  metacarpo- 
phalangeal joint  of  the  thumb,  and  the  other  at  the 
same  point  of  the  little  finger.  Both  extend  up  to  the 
elbow,  the  same  as  the  long  wire  splint.  If  there 
should  be  any  displacement  in  the  opposite  direction, 
the  pad  must  be  applied  on  the  ulnar  side.  No  dorsal 
splint  is  used  in  this  variety.  After  the  dressing  is 
finished,  the  skiagram  verifies  the  proper  position  of 
the  fragments.     In  case  the  tendency  to  displacement 


: 


Jll>- 


Fig.  83. — Forcible  reduction. 


can  not  be  overcome,  a  plaster-of-Paris  dressing  is 
applied  (Fig.  82),  while  forcible  extension  and  counter- 
extension  are  used.  (Fig.  83.)  Whether  the  position 
of  the  fragments  is  correct  should  be  ascertained  by 
the  rays  after  the  plaster-of-Paris  dressing  is  applied. 
(Fig.  84.) 

If  there  be  much  swelling,  wet  applications  may  be 
advantageously  used  by  pouring  Burow's  solution  upon 
the  gauze  bandage,  the  wire  splint  permitting  pene- 
tration of  the  fluid.      (Compare  pp.  48,  67.) 

If  after  the  lapse  of  a  week  agglutination  of  the  frag- 


152 


FRACTURES    OF    SPECIAL  REGIONS. 


tnents  is  obtained  and  no  deformity  is  evident,  then  the 
soft  tissues  must  receive  consideration.  It  is  only  then 
that  short  splints  are  in  order.  They  consist  of  well- 
padded  pieces  of  wood,  extending  from  the  metacarpo- 
phalangeal joint  up  to  the  middle  of  the  forearm. 
After  another  week  a  bracelet,  such  as  is  recommended 
for  the  treatment  of  simple  fissure  (p.  142),  is  so  applied 
as  to  permit  of  free  motion  of  the  fingers.  The  patient 
is  also  told  to  move  his  fingers  as  in  playing  the  piano, 


Fig.  84. — Extra-articular  fracture  of  the  lower  end  of  the  radius  in  a  woman 
thirty-five  years  of  age  ;  skiagram  taken  through  the  plaster-of- Paris  dressing  (two 
weeks  after  the  injury). 


also  to  use  the  marbles,  as  described  in  the  treatment 
of  the  fissure. 

After  the  third  week  massage  treatment  is  indicated, 
active  as  well  as  passive  motion  of  the  joint  being 
employed  at  the  same  time.  The  results  of  these 
simple  methods  are  just  as  good  as,  if  not  better  than, 
those  obtained  by  the  numerous  most  complicated 
apparatus  often  advised  for  the  same  purpose.  If  all 
the  points  of  these  manipulations  dictated  by  simple 


AMERICAN 
POCKET 
MEDICAL 
DICTIONARY 


THE  AMERICAN  POCKET 
MEDICAL  DICTIONARY.  Edited 
by  "W.  A.  Newman 
Dorland,A.M.,M.D., 
Assistant  Obstetrician 
to  the  Hospital  of  the 
University  of  Penn- 
sylvania; Fellow  of  the  American 
Academy  of  Medicine,  etc.  Over  500 
pages.  Full  leather,  limp,  with  gold 
edges.  Price,  $1.00  net;  with  patent 
thumb  index,  $1.25  net. 

SECOND  EDITION,  REVISED. 

This  is  the  ideal  pocket  lexicon- — It  is  an 
absolutely  new  book,  and  not  a  revision  of 
any  old  work. — It  is  complete,  defining  all 
the  terms  of  modern  medicine,  and  forming 
an  unusually  full  vocabulary. — It  gives  the 
pronunciation  of   all    the   terms. — It   makes  a 


"One  of  the  handiest  lit'le  dictionaries  for  the 
pocket  that  we  have  ever  seen.  Its  definitions  are 
short,  concise,  and  complete,  so  that  it  contains 
within  a  small  space  as  many  words,  satisfactorily- 
defined,  as  are  found  in  some  of  the  much  larger 
volumes." — American  Medico-Surgical  Bulletin. 


special  feature  of  the  newer  words  neglected 
by  other  dictionaries. — It  contains  a  wealth  of 
anatomical  tables  of  special  value  to  students 
in  preparing  for  examinations. — The  new  or 
"reformed"  spelling  is  employed. — A  handy 
volume  indispensable  to  every  medical  man.  & 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W\  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


AMERICAN 
POCKET 
MEDICAL 
DICTIONARY 


THE  AMERICAN  POCKET 
MEDICAL  DICTIONARY.  Edited 
by  "W.  A.  Newman 
Dorland,A.M.,M.D., 
Assistant  Obstetrician 
to  the  Hospital  of  the 
University  of  Penn- 
sylvania; Fellow  of  the  American 
Academy  of  Medicine,  etc.  Over  500 
pages.  Full  leather,  limp,  with  gold 
edges.  Price,  $1.00  net;  with  patent 
thumb  index,  $1.25  net. 

SECOND  EDITION  REVISED. 

This  is  the  ideal  pocket  lexicon. — It  is  an 
absolutely  new  book,  and  not  a  revision  of 
any  old  work.— It  is  complete,  defining  all 
the  terms  of  modern  medicine,  and  forming 
an  unusually  full  vocabulary. — It  gives  the 
pronunciation  of   all    the   terms. — It   makes  a 


"One  of  the  handiest  litile  dictionaries  for  the 
pocket  that  we  have  ever  seen.  Its  definitions  are 
short,  concise,  and  complete,  so  that  it  contains 
within  a  small  space  as  many  words,  satisfactorily 
defined,  as  are  found  in  some  of  the  much  larger 
volumes." — American  Medico-Surgical  Bulletin. 


special  feature  of  the  newer  words  neglected 
by  other  dictionaries. — It  contains  a  wealth  of 
anatomical  tables  of  special  value  to  students 
in  preparing  for  examinations. — The  new  or 
"reformed"  spelling  is  employed. — A  handy 
volume  indispensable  to  every  medical  man.  Jt 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W".  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


SHOULDER    AND    UPPER    EXTREMITY. 


OO 


common  sense  are  observed,  and  if  their  proper  exe- 
cution is  certified  by  the  skiagram,  surgical  clinics  will 
no  longer  furnish  so  much  testimony  of  deformities 
and  functional  impairment  following  fracture  of  the 
lower  end  of  the  radius. 

In  cases  of  severe  functional  disturbance  of  the  joint 
produced  by  the  agglutination  of  the  fragments  in  a 
displaced  position  the  author  has  repeatedly  succeeded 
in  reducing  the  deformity  by  osteotomy.  In  every  case 
the  functional  result  has  been  very  satisfactory. 

(e)  Fractures  of  the  lower  end  of  the  radius  combined 


Fig.  85. — Extra-articular  fracture  of  the  lower  end  of  the  radius  combined 
with  irregular  fissure  of  the  head  of  the  ulna  ^  of  an  inch  above  the  epiphysis  in 
a  woman  twenty-nine  years  of  age  (one  day  after  the  injury). 


with  fissure  or  fracture  of  the  head  of  the  ulna  (Fig.  85) 
are  of  moderate  frequency.  This  combination  was 
entirely  unknown  before  the  Rontgen  discovery.  It 
was  the  privilege  of  the  author  to  call  attention  to  its 
existence  first.*  Since  that  time  he  has  observed  it  in 
eleven  per  cent,  of  his  cases  of  fracture  of  the  lower 


*  See    "The    Rontgen    Rays    in    Surgery," 
Magazine,"  May,  1897. 


International   Medical 


*54 


FRACTURES    OF    SPECIAL    REGIONS. 


end  of  the  radius.  This  surprising  experience  was 
corroborated  by  Kahleyss.* 

In  case  of  fissure  of  the  ulna  no  displacement  is 
present  and  the  symptoms  are  essentially  the  same  as 
those  of  the  complete  fractures  described  on  page  148. 

In  the  much  rarer  event  of  complete  fracture  of  the 
ulna  the  symptoms  of  sideward  displacement  are  well 
pronounced.  This  combination  is  the  main  cause  of 
the  impairment  of  supination  and  pronation. 

The  treatment  is  the  same  as  that  of  complete  frac- 


Fig.  86. — Fracture  of  the  lower  end  of  the  radius  combined  with  fracture  of 
the  styloid  process  of  the  ulna  in  a  man  thirty-eight  years  of  age  (two  days  after 
the  injury). 

tures  connected  with  sideward  displacement  (see  p. 
150),  sideward  pressure  by  attaching  an  adhesive 
plaster  pad  over  the  ulnar  fragment  after  reduction 
being  well  kept  up. 

(f)  Fracture  of  the  lower  end  of  the  radius  combined 
with  fracture  of  the  styloid  process  of  the  ulna  (Fig.  86) 
is  extremely  frequent.     In  the  author's  cases  this  com- 


*  "  Beitrag  zur  Kenntniss  der  Fracturen  am  unteren  Ende  des  Radius," 
"  Deutsche  Festschrift  fiir  Chirurgie,"  12.  November,  1897. 


SHOULDER  AND  UPPER  EXTREMITY. 


155 


bination  represents  thirty-two  per  cent,  of  all  cases  of 
fracture  of  the  lower  end  of  the  radius.  In  this  variety 
the  radio-ulnar  joint  is  always  more  or  less  involved. 

The  treatment  is  the  same  as  that  of  the  complete 
fractures  connected  with  sideward  displacement,  side- 
ward pressure  by  attaching  adhesive  plaster  pads  over 


Fig.  87. — Excessive  callus  formation 
after  extra-articular  fracture  of  the 
radius  in  a  boy  fifteen  years  of  age, 
followed  by  considerable  disturbance  in 
pronation  and  supination  (four  months 
after  the  injury). 


Fig.  88. — Excessive  callus  for- 
mation after  extra-articular  fracture 
in  a  girl  sixteen  years  of  age.  No 
functional  disturbance  (three  weeks 
after  the  injury). 


the  fragments  after  reduction  being  rigidly  maintained. 
In  obstinate  cases  the  resection  of  the  process  is  some- 
times indicated. 

In  case  of  functional  disturbances  caused  by  ex- 
cessive callus  formation  osteotomy  has  to  be  resorted 
to.  (Fig.  87.)  Simple  deformity  not  connected  with 
any  functional  disturbance  would  not  indicate  chiseling 
off  the  callus.      (Fig.  88.) 


IS6 


FRACTURES    OF    SPECIAL    REGIONS. 


Deformities  causing  severe  disturbances  of  the  func- 
tion of  the  wrist  may  be  corrected  by  performing  oste- 
otomy in  the  radial  fracture-line.  Sometimes,  in  ad- 
dition, a  wedee  must  be  exsected  from  the  ulna  in 
order  to  permit  of  perfect  reposition. 

If  rotation  is  impossible,  the  head  of  the  ulna  should 
be  resected.  The  author's  experience  comprises  four 
such  cases,  in  persons  of  thirty-three  to  forty  years,  in 


Fig.  89. — Fracture  of  radius  and  ulna  in  a  boy  nine  years  of  age.  Angular 
displacement  not  reduced  ;  abundant  callus  formation  beginning  (six  weeks  after 
the  injury). 

which  osteotomy  gave  gratifying  results.  Adults  who 
must  support  themselves  by  the  work  of  their  hands 
should  invariably  be  subjected  to  radical  operative  cor- 
rection.    Only  aged  persons  should  be  exempted. 

3.  Fracture  of  Radius  and  Ulna  Together. — 
Simultaneous  fractures  of  radius  and  ulna  are  of  mod- 
erately frequent  occurrence  and  are  caused  by  direct 
as  well  as  by  indirect  violence.  Especially  in  early 
childhood,  where  the  typical  fracture  of  the  radius  is 


SHOULDER    AND    UPPER    EXTREMITY. 


157 


rare  on  account  of  the  soft  condition  of  the  epiphyseal 
end  of  that  bone,  a  fall  on  the  outstretched  hand  pro- 
duces the  fracture  of  both  bones.  Sometimes  there  is 
only  an  infraction,  if  children  are  exceptionally  con- 
cerned. 

The  centers  of  both  diaphyses  are  most  liable  to 
fracture.  It  is  only  by  direct  violence  (falling  of  heavy 
objects,  gunshot  wounds)  that  the  other  portions  of  the 
bones  of  the  forearm  become  fractured. 

The  signs  are  generally   well   marked.      Displace- 


Fig.  90. — Fracture  of  radius  and  ulna  (green-stick  variety)  in  a  boy  twelve 
years  of  age,  showing  cohering  periosteal  and  osseous  portions.  No  ulnar  and 
only  slight  radial  displacement  (two  days  after  the  injury). 


ment  always  being  present,  the  bones  form  a  slight 
anterior  or  posterior  angle.  (Fig.  89.)  If,  as  it  hap- 
pens in  children,  there  are  still  cohering  portions 
of  periosteum  and  bone,  the  displacement  may  be 
insignificant.  (Fig.  90.)  There  is  intense  pain,  ab- 
normal mobility,  and  loss  of  function.  Sometimes  the 
displacement  is  so  great  that  the  fragments  overlap. 
Then    considerable    shortening    of    the    arm    will     be 


158  FRACTURES    OF    SPECIAL    REGIONS. 

noticed.  (Fig.  91.)  Sometimes  one  of  the  two  bones 
is  only  fissured  ;  then  there  is  but  little  displacement, 
as  a  rule,  in  the  other.      (Fig.  92.) 

The  treatment  consists  in  the  application  of  long 
wooden  splints,  after  reduction  has  been  accomplished 
by  forcible  extension  and  counterextension.  The  very 
wide,  well-padded  splints  (one  on  the  flexor  and  one 
on  the  extensor  side)  must  reach  from  the  metacarpus 
up  above  the  elbow,  the  hand  being  kept  in  supination. 


Fig.  91. — Fracture  of  radius  and  ulna  in  a  man  thirty-nine  years  of  age,  showing 
overlapping  of  fragments  (eight  weeks  after  the  injury). 

This  position  prevents  fusion  of  both  bones  (ossi- 
fication of  the  ligament).  After  the  lapse  of  a 
week  a  plaster-of-Paris  dressing  can  be  applied,  while 
the  elbow  is  in  the  rectangular  position.  After  three 
weeks,  massage  treatment,  active  and  passive  motion, 
especially  rotatory  manipulations,  are  instituted. 

In  intrauterine  fracture  of  the  radius  and  ulna  wir- 
ing of  the  bones  has  to  be  resorted  to.  In  the  case 
illustrated  by  figure  93  (see  also  Figs.  1,  2)  the  author 
has  succeeded  in  uniting  the  fragments  in  this  manner. 


SHOULDER    AND    UPPER    EXTREMITY.  I  59 

Pseudoarthrosis  of  the  antibrachium  is  rarer  than  that 
of  the  humerus.  It  is  also  caused  by  the  intervention 
of  muscular  tissue.  It  is  especially  the  upper  third 
whose  anatomic  conditions  seem  to  favor  it.  If  one 
portion  of  the  arm  is  in  pronation  and  the  other  one  in 
supination,  the  separation  of  the  fragments  may  be- 
come so  great  that  the  upper  end  of  the  radial  frag- 
ment unites  with  the  lower  one  of  the  ulna.  Such 
conditions  can  be  remedied  only  by  osteotomy.     If  the 


Fig.  92. — Fracture  of  the  radius  combined  with  fissure  of  the  ulna — slight 
axial  displacement  of  the  radius — in  a  man  twenty-two  years  of  age  (ten  days  after 
the  injury). 

radius  is  concerned  at  its  upper  third,  its  deep  situa- 
tion causes  considerable  technical  difficulties  for  opera- 
tion 

If  radius  and  ulna  grow  together  laterally,  so  that  a 
bridge  is  formed  that  fills  the  interosseal  space,  supina- 
tion is  prevented.  Compare  figures  63  and  69  as 
counterparts.  Then  the  division  of  the  bridge  by  the 
use  of  a  chisel  or  a  Gigli  wire  saw  is  indicated,  the 
arm  being  immobilized  in  supination  afterward. 

In  compound  fractures  the  question  of  amputation 


i6o 


FRACTURES    OF    SPECIAL    REGIONS. 


often  arises.  As  previously  emphasized  in  Part  I  of 
this  book,  conservative  principles  should  be  upheld 
to  the  utmost.  Sometimes  under  the  most  unfavorable 
circumstances — extensive  comminuted  fractures  and 
necrosis,  laceration  of  the  flexor  and  extensor  muscles, 
necrosis  of  a  large  skin-portion — still  fairly  good  func- 
tion of  the  extremity  is  finally  obtained. 

Loose  bone-splinters  must  be  removed  and  sharp 
edges  should  be  cut  away  with  bone-shears.  Lacer- 
ated tendons  must   be  trimmed   and  carefully  united 


Fig.  93. — Intrauterine  fracture  of  radius  and  ulna,  united  by  osteorrhaphy,  in 
a  boy  of  three  months.  Radial  wire  extracted  ;  ulnar  wire  still  in  situ  (four 
weeks  after  operation). 


with  thin  formalin  catgut.  Necrotic  skin-portions  must 
be  exsected.  Skin-grafting  should  not  be  attempted 
before  there  is  a  normally  granulating  surface.  As 
long  as  there  is  much  reaction,  a  wire  splint  should  be 
applied  in  vertical  suspension,  which  method  permits 
of  the  permanent  application  of  an  antiseptic  lotion. 
(Compare  section  on  Compound  Fractures,  p.  67.) 
When  the  swelling  has  subsided  and  the  suppuration 
has  become  scant,  a  moss  splint  or  a  fenestrated 
plaster-of-Paris  dressing  should  be  chosen. 


The  series  of  books  included  under  this  title  are 
translations  into  English  of  the  world-famous 
"Lehmann  medicinische  Handatlanten."  For 
scientific  accuracy,  pictorial  beauty,  compact- 
ness, and  cheapness 


SAUNDERS' 

MEDICAL 

HAND-ATLASES 


these  books  surpass 
any  similar  volumes 
ever  published.  Each 
volume  contains 
from  50  to  J00  col- 
ored plates,  executed  by  the  most  skilful  German 
lithographers.  A  full  description  of  each  plate 
is  given,  together  with  a  condensed  outline  of 
the  subject  to  which  the  book  is  devoted.  <£  <£ 
The  great  advantage  of  natural  pictorial  repre- 
sentation is  indisputable.  For  lasting  and  prac- 
tical knowledge,  one  accurate  illustration  is  better 
than  several  pages  of  dry  description.  >£  <£>  <£ 
These  Atlases  offer  a  ready  and  satisfactory 
substitute  for  clinical  observation,  available  only 
to  the  residents  of  large  medical  centers.  <£  <£ 
By  reason  of  their  projected  universal  transla- 
tion and  reproduction  the  publishers  have  been 
enabled  to  secure  for  these  Atlases  the  best  artis- 
tic and  professional  talent,  to  produce  them  in 
the  most  elegant  style,  and  yet  to  offer  them  at 
a  price  heretofore  unapproached  in  cheapness. 
The  success  of  the  undertaking  is  demonstrated 
by  the  fact  that  volumes  have  already  appeared 
in  German,  English,  French,  Italian,  Russian, 
Spanish,  Japanese,  Dutch,  Danish,  Swedish, 
Roumanian,  Bohemian,  and  Hungarian.  -J&  J* 
The  same  careful  and  competent  editorial  su- 
pervision will  be  secured  in  the  English  edition 
as  in  the  originals,  the  translations  being  edited 
by  the  leading  American  specialists.    <£    -J*    J* 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  "Walnut  St.,  Philadelphia. 


Saunders'  Medical  Hand-Atlases. 


As  it  is  impossible  to  realize  the  beauty  and 
cheapness  of  these  Atlases  without  an  opportunity 
to  examine  them,  we  make  the  following  offer: 
Any  one  of  these  books  will  be  sent,  post-paid, 
upon  request.  If  you  want  the  book,  you  have 
merely  to  remit  the  price ;  if  not,  return  the  book. 

VOLUMES  NOW  READY. 

Atlas  of  Internal  Medicine  and  Clinical  Diagnosis.  By 
Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus 
A.  Eshner,  M.D.,  Professor  of  Clinical  Medicine, 
Philadelphia  Polyclinic.     68  colored  plates. 

Cloth,  #3.00  net. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of 
Vienna.  Edited  by  Frederick  Peterson,  Al  D., 
•Chief  of  Clinic,  Nervous  Dept.,  College  of  Physicians 
and  Surgeons,  New  York.  With  120  colored  figures 
on  56  plates  ;   193  half-tone  illustrations. 

Cloth,  &3.50  net. 

Atlas  of  Diseases  of  the  Larynx.    By  Dr.  L.  GruNWALD, 

of  Munich.  Edited  by  Charles  P.  Grayson,  M.D., 
Lecturer  on  Laryngology  and  Rhinology  in  the  Uni- 
versity of  Pennsylvania.  With  107  colored  figures 
on  44  plates,  and  25  text-illustrations. 

Cloth,  $2.50  net. 

Atlas  of  Operative  Surgery.  By  Dr.  O.  Zuckerkandl, 
of  Vienna.  Edited  by  J.  Chalmers  DaCosta, 
M.D.,  Clinical  Professor  of  Surgery,  Jefferson 
Medical  College,  Philadelphia;  Surgeon  to  the 
Philadelphia  Hospital.  With  24  colored  plates, 
and  217  text-illustrations.  Cloth,  $3.00  net! 

Atlas  of  Syphilis  and  \he  Venereal  Diseases.  By  PROF. 
Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L. 
Bolton  Bangs,  M.  D.,  Professor  of  Genito-Urinary 
Surgery,  University  and  Bellevue  Hospital  Medical 
College,  New  York..     With  71  colored  plates. 

Cloth,  $3.50  net. 

Atlas  of  External  Diseases  of  the  Eye.  By  Dr.  O. 
Haab,  of  Zurich.  Edited  by  G.  E.  de  Schweinitz, 
M.D.,  Professor  ot  Ophthalmology,  Jefferson  Medi- 
cal College,  Philadelphia.  With  76  colored  illus- 
trations on  40  plates.  Cloth,  $3.00  net. 

Atlas  of  Skin  Diseases.  By  Prof.  Dr.  Franz  Mracek, 
of  Vienna.  Edited  by  Henry  W.  Stelvvagon, 
M.D.,  Professor  of  Dermatology,  Jefferson  Medi- 
cal College,  Philadelphia.  With  63  colored  illus- 
trations and  39  beautiful  half-tones.  Cloth,  £3.50  net. 

Atlas  and  Epitome  of  Special  Pathological  Histology. 
By  Dr.  H.   Durck,  of  Munich.     Edited  by  Ludvig 

Hkktuen,  M.  I).,  Professor  of  Pathology,  Rush  Medi- 
cal College,  Chicago.  Two  volumes,  with  about  120 
colored  plates,  numerous  text-illustrations,  and  copious 
text.      Volume  I.  ready  in  April, 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


SHOULDER  AND  UPPER  EXTREMITY. 


161 


HAND  AND   FINGERS. 

Fracture  of  the  bones  of  the  hand  and  finders  are 
classified  as  follows  : 

i.   Fracture  of  the  carpus. 

2.  Fracture  of  the  metacarpus. 

3.  Fracture  of  the  phalanges. 

Fracture  of  the  carpus  is  extremely  rare  and  is 
always  caused  by  direct  violence  (fall  of  heavy  objects). 


Fig.  94. — Supracondylar  fracture  of  first  metacarpus  of  the  little  finger, 
showing  inward  displacement  (thus  also  resembling  dislocation),  in  a  man  twenty- 
eight  years  of  age  (two  weeks  after  the  injury). 

The  ligaments  connecting  these  bones  being  very 
strong,  the  displacement  is  insignificant,  and  therefore 
the  fracture  often  escapes  notice  unless  a  skiagram  is 
taken. 

Abnormal  mobility  and  crepitus  naturally  being  ab- 
sent, pain  and  functional  disturbance  are  the  main 
signs.  This  fracture  is  generally  combined  with  severe 
injuries  of  the  soft  tissues. 

The  treatment  consists  in  applying  a  palmar  wire 
splint.     Immobilization  is  properly  combined  with  the 


l62 


FRACTURES    OF    SPECIAL    REGIONS. 


application  of  antiseptic  lotions,  especially  if  there  be 
simultaneous  injuries  to  the  soft  tissues.     In  the  event 


Fig.  95. — Fracture  of  right  fourth  metacarpus,  showing  displacement,  in  a  man 
thirty  years  of  age  (two  d.iys  after  the  injury). 


Fig.  96. — Dorsal  dislocation  of  the   thumb  (outer  view)  in  a  boy  of  twelve  years 
(four  weeks  after  the  injury). 

of  a  compound  comminuted  fracture  of  a  carpal  bone, 
its  removal  is  indicated. 

After  the  lapse  of  ten  days  massage  treatment  and 
active  and  passive  motion  are  in  order. 


SHOULDER    AND    UPPER    EXTREMITY. 


16 


Fracture  of  the  metacarpus  (Fig.  94),  especially  of 
the  first  metacarpal  bone,  is  very  common,  and  is  also 


Fig-  97- — Dorsal  dislocation  of  the  thumb.      Skiagram  of  figure 


Fig.  98. — Lateral  dislocation  of  thumb  in  a  girl  eight  years  of  age  (six  weeks  after 

the  injury). 

produced  by  direct  violence.     The  interosseous  mus- 
cles pulling  the  upper  fragment  downward,  some  slight 


164 


FRACTURES    OF    SPECIAL    REGIONS. 


displacement  can  always  be  noticed.  (Fig.  95.)  There 
is  also  abnormal  mobility,  crepitus,  local  pain,  and  swell- 
ing.    As  the  Rontgen  rays  have  demonstrated,  a  large 


Fig-  99- — Dorsal  dislocation  of    the  second  phalanx  of    the  thumb  in  a  woman 
thirty  years  of  age  (sixteen  months  after  the  injury). 


Fig.  100. — Supracondylar  fracture  of  the  first  phalanx  of  the  little  finger  in  a  lad 
of  twenty  years  (two  days  after  the  injury). 

numberof  allegeddislocationsand  contusions  are, in  fact, 
separations  of  the  phalangeal  epiphyses  in  childhood. 

The  treatment  is  essentially  the  same  as  that  of  the 
fracture  of  a  carpal  bone,  the  only  point  to  be  specially 


SHOULDER    AND    UPPER    EXTREMITY.  165 

considered  in  this  injury  being  that  an  adhesive  plaster 
pad  should  be  placed  on  the  palm  at  the  seat  of  the 
fracture. 

Massage  must  be  commenced  early.  In  the  excep- 
tional case  of  considerable  displacement  wiring  of  the 
fragments  may  come  into  consideration. 

Fracture  of  the  phalanges  is  nearly  always  caused 
by  direct  violence  (the  fingers  being  caught  or  held  in 
a  door,  etc.).  Exceptionally,  it  is  produced  by  indirect 
violence  (fall  on  the  fingers  or  overextension  during 
wrestling,  etc.). 

The  signs  are  typical,  and,  in  fact,  so   apparent  that 
they  should  hardly  need  description.    Still,  fracture   is 
sometimes  confounded  with 
dislocations.     As  to  contra- 
distinction, compare  figures 
96,  97,  98,  and  99. 

The  treatment  consists  in 
keepino-  the  fragments  well 

r      &  &  Fig.  101.  —  Splint  for  phalangeal 

immobilized  by  Small  Splints  fracture  (after  Hoffa). 

of     wood      or     pasteboard 

(Fig.  101),  after  thorough  reduction  is  accomplished. 
The  splints  are  to  be  fastened  by  starched  gauze 
bandages.     Union  is  generally  perfect  in  two  weeks. 

If  the  fracture  be  comminuted  or  compound,  ex- 
treme conservatism  should  prevail.  It  is  surprising 
how  often  a  shattered  phalanx  is  entirely  restored  to 
its  function  under  thorough  aseptic  precautions.  The 
severed  fragments  being  removed,  sometimes  all  that  is 
left  of  the  phalanx  is  represented  by  a  thin  bony  frag- 
ment ;  nevertheless,  this  may  develop  into  a  useful 
phalanx  again,  provided  enough  periosteum  is  left  in 
its  place. 


1 66 


FRACTURES    OF    SPECIAL    REGIONS. 


FRACTURES  OF   THE  PELVIS  AND 
THE  LOWER   EXTREMITY. 

PELVIS. 

Fractures  of  the  pelvis  represent  less  than  one  per 
cent,  of  all  fractures,  and  are  similar  to  those  of  the 
skull  and  thorax,  inasmuch  as  they  occur  in  an  osseous 
ring,  irregularly  composed  of  several  bones :  namely, 
the  os  ilii,  the  os  pubis,  the  os   ischii,  and   the   sacrum 


Fig.  102.  —  Fracture  of  pelvis,  fragments  boring  into  ileopsoas  muscle  (after  Hoffa). 


and  coccyx.  They  concern  either  one  of  these  bones 
individually  or  the  pelvic  ring  as  a  whole.     (Fig.  102.) 

They  are  generally  caused  by  direct  violence,  as,  for 
instance,  by  a  heavy  weight  falling  upon  the  pelvis,  or 
by  the  patient  falling  from  a  high  point,  or  by  his  being 
crushed  between  the  buffers  of  two  railroad-cars  while 
they  are  being  coupled,  or  by  the  passage  of  a  wagon- 
wheel  across  the  lower  abdomen. 

In   the  first   event — -fracture  of  an  individual  pelvic 


PELVIS    AND     LOWER    EXTREMITY.  \6j 

bone — palpation  will  always  reveal  separation  ot  at 
least  a  single  fractured  bone-portion.  Abnormal 
mobility,  displacement,  and  consequently  crepitus,  are 
always  present.  The  abdominal  organs  are  but  sel- 
dom injured. 

The  treatment  consists  in  reposition  as  far  as  is  pos- 
sible, and  immobilization  by  applying  a  long  splint 
extending  from  the  external  malleolus  to  the  axilla. 
(Compare  Fig.  103.)  Union  in  a  deformed  position, 
while,  of  course,  undesirable,  is  seldom  followed  by 
any  functional   disturbance. 

Fractures  of  the  pelvic  ring  are  always  to  be  re- 


Fig.  103. — -Long  splint  applied  during  extension,  in  fracture  of  the  pelvis  or  the 
neck  of  the  femur. 

garded  as  of  importance,  since  they  are  generally 
accompanied  by  simultaneous  injuries  either  of  the 
abdominal  viscera  or  of  the  urethra,  the  sciatic  nerve, 
or  the  femoral  vessels. 

The  signs  consist  in  ecchymosis,  localized  pain,  which 
is  severely  intensified  on  pressure,  inability  to  lift  the 
lower  limb,  and  marked  displacement.  In  all  cases  of 
suspected  pelvic  fracture  the  rectum  and  urethra  must 
be  carefully  explored  also.  In  trying  to  press  both 
iliac  bones  together  an  intense  circumscribed  pain  is 
produced,  which  may  direct  attention  to  the  point  of 
fracture. 


1 68  FRACTURES    OF    SPECIAL    REGIONS. 

Laceration  of  the  urethra  as  well  as  abdominal  in- 
juries are  treated  upon  general  surgical  principles. 
In  urethral  injuries  permanent  catheterization  should 
be  employed.  It  is  the  significance  and  extent  of 
these  concomitant  injuries  that  determine  the  course 
of  this  dreaded  fracture  type. 

The  best  treatment  consists  in  the  application  of  a 
plaster-of- Paris  dressing  surrounding  the  abdomen, 
pelvis,  and  thigh  (Fig.  1 1 6),  or  in  the  application  of  a 
long  splint.  (Fig.  103.)  Extension  also  sometimes 
proves  useful.     (Fig.  10.) 

THIGH. 

Fractures  of  the  thigh  represent  about  six  per  cent, 
of  all  fractures.  They  are  divided  into  those  of  the 
upper  end,  those  of  the  diaphysis,  and  those  of  the 
lower  end  of  the  femur.  In  adults  they  generally 
occur  in  the  lower,  and  in  aged  persons  in  the  upper, 
end,  while  in  children  the  middle  third  is  most  fre- 
quently involved.  They  occur,  however,  in  any  part 
of  the  bone  in  children. 

Fracture  of  the  Upper  End  of  the  Femur. 
— Fracture  of  the  upper  part  of  the  femur  concerns 
either  its  head  or  neck  or  the  trochanteric  region. 
Anatomically,  it  is  to  be  divided  into  epiphyseal  sepa- 
ration of  the  upper  end  of  the  femur,  in  fracture  of 
the  neck  (intra-  and  extracapsular),  the  isolated  frac- 
ture of  the  trochanter  major,  and  the  infratrochanteric 
fracture. 

I.  Epiphyseal  separation  of  the  upper  end  of  the  femur 
occurs  before  the  twentieth  year,  and  is  extremely  rare. 
The  epiphysis  being  intra-articularly  situated,  it  is  ob- 
vious that  it  is  but  seldom  reached  by  an  injury.    As 


PELVIS    AND     LOWER    EXTREMITY.  1 69 

a  rule,  this  fracture  is  produced  by  a  sudden  wrench  or 
sprain. 

The  signs  consist  mainly  in  abnormal  mobility,  in- 
tense local  pain,  and  soft  crepitus.  There  is  also 
shortening-  and  elevation  of  the  trochanter  major 
above  Nelaton's  line.  It  is  easily  confounded  with 
dislocation,  hip-disease,  or  infantile  paralysis.  It  is 
often  overlooked  until  the  patient  commences  to  walk. 
Ununited  fracture  may  cause  lameness. 

The  treatment  is  the  same  as  that  of  a  fracture  of 
the  femoral  neck.  In  ununited  fracture  operative  in- 
terference is  indicated.  (Compare  section  on  Wiring 
the  Bones,  p.  70.) 

II.  Fracture  of  the  neck  of  the  femur  seldom  occurs 
before  the  fiftieth  year  of  life,  and  may  be  caused  by 
direct  as  well  as  by  indirect  violence  (fall  upon  the  hip, 
blow  upon  the  trochanter  major).  The  line  of  fracture 
is  either  in  the  intertrochanteric  line  or  at  the  femoral 
head,  or  between  these  points.  Its  direction  is  either 
transverse  or  oblique  to  the  axis  of  the  neck.  Accord- 
ingly, intra-  and  extracapsular  fractures  of  the  neck 
of  the  femur  are  distinguished,  analogous  to  the  frac- 
tures of  the  anatomic  and  surgical  necks  of  the 
humerus. 

[a]  Intracapsular  fracture  (Fig.  104)  is  most  fre- 
quent in  aged  persons,  a  prevalence  that  is  explained 
by  the  senile  changes  at  the  angle  of  the  thigh-bone. 
While  in  earlier  life  the  angle  of  the  neck  to  the 
shaft  is  still  oblique,  it  becomes  rectangular  in  elderly 
people.  Thus  the  bone  becomes  more  fragile,  so  that 
it  may  fracture  even  after  trifling  injuries,  such  as,  for 
instance,  simply  falling  on  a  carpet. 

The  line  of  fracture  is  transverse  and  is  generally 


170 


FRACTURES    OF    SPECIAL    REGIONS. 


indentated,    so     that     impaction     is    greatly    favored. 
Sometimes  there  is  only  infraction. 

The  signs  of  intracapsular  fracture  are  but  little 
marked  if  there  be  infraction  or  impaction,  so  that  no 
displacement  is  produced.  The  only  signs  would 
then  be  the  local  pain  and  functional  disorder  of  the 
leg,  so  that  contusion  of  the  hip  may  be  thought  of. 


Fig.  104. — Intracapsular  fracture  in  a  man  fifty-five  years  of  age,  showing 
absence  of  osseous  union ;  head  appearing  to  be  free  in  the  acetabulum.  Fibrous 
union  permits  of  limited  amount  of  motion  (two  years  after  the  injury). 


In  such  cases  elucidation  by  the  Rontgen  rays  is 
urgently  required. 

If  there  is  displacement,  the  signs  are  very  distinct. 
Then  the  lea-  is  rotated  outward  and  is  shortened  to 
the  extent  of  at  least  an  inch.  Crepitus  and  pain  are 
also  then  present. 

If  the  fracture  be  not  caused  by  a  fall  upon  the  hip, 


PELVIS    AND     LOWER    EXTREMITY.  171 

ecchymosis,  if  present  at  all,  will  be  insignificant.  The 
pain  is  severe  on  the  seat  of  fracture  and  increases  if 
the  thigh  is  flexed.      Crepitus  is  absent. 

Treatment  meets  with  great  difficulties.  These  are 
caused,  in  the  first  place,  by  the  poor  chance  of 
approximating  the  fragments,  the  diastasis  of  which  is 
increased  by  the  intracapsular  blood  extravasation. 
The  upper  fragment,  the  sole  connection  of  which  is 
the  ligamentum  teres,  has  but  a  poor  arterial  supply. 
The  osteoblasts,  which  regenerate  new  bone-tissue 
from  the  spongious  portion  of  the  bone  only,  are  scant, 
since  there  is  merely  a  cartilaginous  coat ;  and  callus 
formation  is  consequently  poor.  The  most  favorable 
outcome  to  be  looked  for  is  therefore  a  superficial 
approximation  of  the  fragments  by  a  few  fibrous  bands. 

Another  and  still  more  important  difficulty  is  pre- 
sented by  the  general  condition  of  the  patients,  who 
are  usually  aged,  and  therefore  inclined  to  hypostatic 
pneumonia  when  condemned  to  a  prolonged  sick-bed. 
It  is  especially  here  that  the  ambulatory  plaster-of- Paris 
dressing  shows  its  great  advantages.      (See  p.  43.) 

This  dressing  is  applied  at  once  after  the  integu- 
ment is  well  oiled.  Reposition  is  made  after  the  leg 
is  surrounded  first  by  an  ordinary  plaster-of-Paris 
dressing  from  the  metatarsus  up  to  the  knee.  It  is 
then  easy  to  reduce  the  fragment  by  pulling  on  the 
foot,  while  counterextension  is  exercised  on  the  pelvis. 
The  patient's  trunk  and  pelvis  are  elevated  throughout 
the  time  when  this  procedure  is  carried  out.  Now 
around  the  tubera  ossis  ischii  and  the  trochanter  a 
seating-ring  is  formed,  which,  after  being  hardened,  is 
connected  with  the  dressing  of  the  lower  end.  This  is 
accomplished  by  many  turns  of  plaster-of-Paris  ban- 


172  FRACTURES    OF    SPECIAL    REGIONS. 

dages,  below  which  a  thin  wooden  fiber  for  firmer  sup- 
port is  interposed.      (Fig.  6.) 

Patients  are  sometimes  able  to  pfo  about  on  crutches 
as  early  as  two  days  after  the  fracture  was  sustained. 
It  is  needless  to  call  attention  to  the  fact  that  in  each 
case  the  circulation  is  likely  to  be  well  kept  up  and  the 
danger  of  hypostasis  in  the  lungs  is  often  counteracted. 

If  for  any  reason  the  ambulatory  dressing  can  not  be 
applied,  Buck's  extension  (see  Fig.  10),  in  connection 
with  a  long  extension  splint  (see  Fig.  103),  must  be 
employed.  Great  care  should  then  be  taken  that  no 
pressure  is  made  upon  the  sacrum,  where  decubitus 
may  become  detrimental. 

The  position  of  the  upper  parts  of  the  body  must 
be  frequently  changed  and  the  patient  should  be  ad- 
vised to  sit  up  in  bed  frequently  and  to  inspire  deeply 
in  order  to  avoid  circulatory  stasis. 

Where  reposition  is  found  to  be  impossible,  and  the 
displacement  is  of  considerable  extent,  uniting  the 
fragments  with  ivory  pegs  has  repeatedly  been  sug- 
gested. While  the  idea  of  this  procedure  is  irre- 
proachable from  a  theoretic  standpoint,  it  can  not  be 
indorsed,  because  it  has  shown  unsatisfactory  results  in 
practice.  In  several  cases  it  was  also  followed  by  fatal 
consequences. 

It  is  self-evident  that  in  cases  of  infraction  and 
impaction,  where  naturally  there  is  no  displacement,  the 
results  are  in  general  most  satisfactory. 

(5)  Extracapsular  fracture  of  the  neck  of  the  femur 
(Fig.  105)  is  generally  produced  by  direct  violence  (fall 
upon  the  hip  or  blow  on  the  trochanter  major).  The 
direction  of  the  fracture  is  usually  in  the  intertrochan- 
teric line. 


PELVIS    AND     LOWER    EXTREMITY. 


17, 


The  fracture  may  be  incomplete,  in  which  event  it  is 
only  the  posterior  cervical  portion  that  is  clearly 
divided,  while  the  thicker  anterior  portion  shows  infrac- 
tion only. 

Much  more  frequently  the  fracture  is  complete,  in 
which  case  the  trochanter  as  well  as  the  head  of  the 


Fig.  105. — Extracapsular  fracture  of  the  neck  of  the  femur  (after  Hoffa). 

femur  may  be  so  involved  that  there  are  several  dis- 
tinct fragments. 

The  signs  are  ecchymosis,  shortening,  and  outward 
rotation.  In  impaction  (Fig.  106)  the  shortening  sel- 
dom exceeds  iy£  inches;  but  if  there  is  no  impaction, 
the  shortening  may  amount  to  four  inches.  Another 
important  sign — the  higher  situation  of  the  trochanter 


i/4 


FRACTURES    OF    SPECIAL    REGIONS. 


major — can  be  elicited  by  measuring  the  distance 
from  the  anterior  superior  spine  to  the  knee,  which  is 
found  shorter  than  that  of  the  uninjured  extremity. 

If  there  is  any  displacement,  crepitus  can  be  de- 
tected invariably.  Local  pain,  tenderness,  and  swell- 
ing are  also  seldom  absent.  Ordinarily,  there  is  entire 
loss  of  function  ;  but  in  impacted  extracapsular   frac- 


Fig.  106. — Extracapsular  fracture  of  the  neck  of  the  femur  in  a  woman 
twenty-six  years  of  age  ;  considerable  functional  disturbance  (two  months  after 
the  injury). 

tures  it  has  repeatedly  been  observed  that  the  patients 
were  able  to  walk  a  short  distance. 

The  diagnosis  of  this  fracture  type  may  become 
difficult  if  neither  shortening  nor  rotation  of  the  leg 
be  present,  and  the  case  may  be  mistaken  for  one  of 
simple  contusion.  Looking  for  crepitus  in  such  cases 
seems,  as  a  rule,  to  be  inadvisable  ;   since  the  rotatory 


PELVIS    AND     LOWER    EXTREMITY.  I  75 

manipulations  necessary  for  eliciting  it  might  be  apt  to 
separate  the  impaction — an  event  which  would  at  least 
make  a  bad  matter  worse.  And  even  in  cases  in 
which  shortening  and  rotation  were  well  marked,  dis- 
location instead  of  fracture  has  been  diagnosticated. 
It  is  true«that  a  certain  similarity  to  iliac  dislocation 
exists,  but  the  latter  can  be  always  excluded,  for  the 
reason  that  the  femoral  head  can  not  be  found  outside 
of  the  acetabulum.  It  should  furthermore  be  consid- 
ered that  in  a  fracture  of  this  kind  the  patient  is 
unable  to  elevate  his  leg  by  active  flexion  ;  while  in 
dislocation  passive  motion  would  be  arrested  to  a 
much  higher  degree  than  in  fracture. 

In  summing  up  the  main  points  of  differentiation  it 
should  be  considered  that  in  dislocation  the  femoral 
head  can  be  palpated  in  the  buttocks.  In  dislocation 
there  is  also  a  moderate  amount  of  resistance  when 
motion  is  made,  while  in  fracture  there  is  little  or  none. 
In  dislocation  the  upper  portion  of  the  hip-joint  is  flat- 
tened, while  in  fracture  there  is  no  change  of  the  nor- 
mal  contours.  If  the  trochanter  appears  widened  and 
enlarged,  the  chances  are  that  the  patient  fell  upon  the 
trochanter,  which  fact  would  point  to  a  fracture.  In 
old  age  fracture  is  the  rule. 

Bony  union,  while  exceptional  in  the  intracapsular 
type,  is  the  rule  in  the  extracapsular  variety,  callus 
proliferation  generally  being  abundant.  Sometimes 
the  callus  is  so  rich  that  free  articular  motion  becomes 
impeded.      (Fig.  107.) 

Union  generally  becomes  perfect  in  six  weeks,  after 
which  the  function  of  the  extremity  is  seldom  found  to 
be  disturbed,  even  if  shortening  to  the  extent  of  an 
inch  has  occurred. 


1/6  FRACTURES    OF    SPECIAL    REGIONS. 


Fig.  107. — Impacted  extracapsular  fracture  of  the  neck  of  the  femur  in  a 
man  fifty-eight  years  of  age  (three  years  after  the  injury),  causing  considerable 
functional  disturbance  on  account  of  the  excessive  callus  proliferation  around  the 
seat  of  the  fracture,  especially  around  the  major  trochanter. 


PELVIS    AND     LOWER    EXTREMITY. 


177 


The  principles  of  treatment  are  the  same  as  those 

for  the  intracapsular  fracture  of  the  neck  of  the  femur. 

III.  Isolated  fracture  of  the  trochanter  major  (Fig.  108 

a  and  b)  is  always  produced  by  direct  violence,  and  is  of 
rare  occurrence.  By  being  pulled  backward  and  upward 
by  the  gluteal  medius  and  minimus  muscles  the  tro- 
chanter appears  considerably  displaced.  The  trochan- 
ter major  is  also  sometimes  separated  in  persons  under 
the  age  of  seventeen  years. 

The  signs   are    sometimes    insignificant,   and    may 


Fig.  108. — Isolated  fracture  of  trochanter  major,      a.   Exterior  view  ;  b,  showing 
diastasis  (after  Hoffa). 


point  to  a  contusion,  since  the  function  of  the  leg  is 
little,  if  at  all,  disturbed  ;  inward  rotation  of  the  leg 
being  possible  by  the  action  of  the  tensor  fasciae  latse 
muscle,  and  outward  rotation  by  that  of  the  obtura- 
tores,  gemelli,  and  quadratus  femoris.  There  is,  of 
course,  no  shortening  such  as  occurs  in  fracture  of 
the  femoral  neck.  Flattening  of  the  trochanteric  area 
is  often  noticed.  The  displaced  fragments  being  nearly 
always  palpable,  differentiation  from  simple  contusion 
should  be  easy. 


178 


FRACTURES    OF    SPECIAL    REGIONS. 


The  treatment  consists  in  immobilization  of  the  leg- 
between  two  sand-bacrs  in  outward  rotation  and  abduc- 


Fig.  109.— Spiral   infratrochanteric  fracture  in  a  boy  of  twelve  years  (fourteen 
hours  after  the  injury),  showing  but  little  sideward  displacement. 


tion,  while  the  hip  and  knee  are  slightly  flexed.      In 
this  position    reduction   of   the   displaced   fragment  is 


PELVIS    AND     LOWER    EXTREMITY.  1 79 

accomplished  to  the  nearest  extent  possible.  An  ad- 
hesive plaster  compress,  to  be  kept  in  situ  by  an 
adhesive  plaster  strip,  should  be  applied  above  and 
behind  the  fragments. 

In  children  a  larcre  abdominofemoral  dressing,  con- 
sisting  of  plaster-of-Paris,  is  recommended.   (Fig.  115.) 

IV.  I nfratrochanteric  fracture  (Fig.  109) — that  is,  frac- 
ture just  below  the  trochanter — is  caused  either  by  indi- 
rect violence  (torsion  of  the  body  while  falling  down), 
causing  a  spiral-shaped  line  (Fig.  109),  or  by  direct 
violence  (blow  or  fall),  which  would  cause  a  trans- 
verse line.  It  is  prevalent  among  the  hard-working 
classes,  and  generally  concerns  adults. 

The  signs,  besides  those  found  in  ordinary  fractures, 
are  the  tilting  upward  of  the  upper  fragments  by  the 
ileopsoas  and  glutaei  muscles,  which  are  inserted  below 
the  trochanter.  This  characteristic  phenomenon  ex- 
plains why  the  upper  fragment  is  sometimes  put  into  a 
right  anorle  to  the  femoral  axis.  In  rotatino-  the  femur 
it  will  be  found  that  the  trochanter  does  not  go  along 
with  the  motion,  abnormal  mobility  being  found  only 
below  the  trochanter. 

The  treatment  requires  reposition  and  extension  in 
a  flexed  position ;  otherwise  it  is  treated  after  the 
same  principles  as  the  fractures  of  the  neck  of  the 
femur. 

Fracture  of  the  Diaphysis  of  the  Femur. — 
Fractures  of  the  diaphysis  of  the  femur  are  far  more 
frequent  than  those  of  the  neck.  Of  all  femoral  frac- 
tures, which  figure  at  six  per  cent,  among  all  fractures, 
they  represent  seventy-one  per  cent.,  while  those  of  the 
neck  amount  to  twenty-nine  per  cent.  only.  They  are 
caused  either  by  direct  or  indirect  violence  or  by  mus- 


i  So 


FRACTURES    OF    SPECIAL    REGIONS. 


cular  action.  Most  of  these  fractures  are  caused  by 
a  downfall  from  a  considerable  height.  The  line  of 
fracture  is  generally  oblique,  if  the  middle  and  upper 
thirds  of  the  shaft  are  concerned  ;  but  in  the  lower  third 
a  transverse  direction  is  the  rule.  Sometimes  a  lonoq- 
tudinal  fracture-line  branches  off  from  the  transverse 
one  into  the  knee-joint  (T-fracture).     These  transverse 


Fig.  no. — Infratrochanteric  fracture  in  an  infant  of  ten  months.  No  effort 
at  reposition  was  made  during  the  first  three  weeks  after  the  injury.  Union 
took  place  with  considerable  deformity  and  slight  functional  disturbance. 


fractures  are  especially  frequent  in  children,  who  may 
sustain  them  in  consequence  of  comparatively  slight 
violence.  Rickety  children  have  a  special  predilec- 
tion for  this  variety.  The  prognosis  is  very  good  in 
childhood,  union  generally  being  perfect  in  from  three 
to  four  weeks. 

Simultaneous  injuries  to  the  femoral  artery  and  vein 


PELVIS    AND     LOWER    EXTREMITY. 


I»I 


are  by  no  means  rare  complications  of  this  fracture 
type. 

The  signs  of  fracture  of  the  diaphysis  are,  first  of  all, 
ecchymosis,  intense  pain,  and  entire  loss  of  function. 
With  the  exception  of  the  rare  cases  where  the  perios- 
teum remained  partly  intact,  or  where  indentation   of 


Fig.  III. — Fracture  of  the  diaphysis  of  the  femur  in  an  infant  six  months  of  age, 
showing  slight  riding  of  fragments  (two  days  after  the  injury). 


the  fractured  ends  keeps  them  fixed  together,  much 
deformity  is  always  present.  (Fig.  1 1 1.)  This  is  caused 
by  the  considerable  degree  of  displacement  more  or 
less  characteristic  of  this  injury.  It  is  naturally  fol- 
lowed by  another  conspicuous  symptom  :  namely,  the 
extreme  shortening,  which  in  some  cases  amounts  to 
as  much  as  six  inches.     Generally,  the  lower  fragment 


182 


FRACTURES    OF    SPECIAL    REGIONS. 


is  rotated  outward  and  pulled  upward  and  to  the  inner 
and  outer  side  of  the  upper  one.  In  fracture  of  the 
upper  third  the  upper  fragment  is  drawn  upward  and 
outward  by  the  action  of  the  ileopsoas  and  glutaei  mus- 
cles, while  the  lower  one  is  drawn  inward  and  upward 
by  the  action  of  the  adductor  muscles.     Thus  riding  of 


Fig.  112. — Typical  oblique  fracture  of  diaphysis  at  the  upper  third  of  the 
femur,  showing  considerable  displacement  and  intervening  of  muscular  tissue,  in  a 
boy  seven  years  of  age  (twenty-four  hours  after  the  injury). 


the  fragments  is  produced  (see  Fig.  112),  so  that  they 
show  an  angle.      (Also  compare  Fig.  1 14.) 

In  the  middle  third  the  upper  fragment  is  drawn 
before  the  lower  one  and  outward  from  it,  if  the  line 
of  fracture  is  situated  above  the  insertion  of  the  ad- 
ductor muscles  ;  but  if  it  occurs  below  that  point,  the 
upper  fragment  is  directed  forward  and  inward. 


PELVIS    AND     LOWER    EXTREMITY.  1 83 

The  same  principle  as  to  displacement  applies  to  all 
fractures  of  the  lower  third.  It  scarcely  need  be  said 
that  such  extensive  displacement  is  always  accompa- 
nied by  abnormal  mobility,  and  that  crepitus  is  never 
absent.  The  shortening  of  the  leg  is  always  consider- 
able. The  rough  edges  of  the  upper  fragment  are 
generally  easily  palpable  above  the  patella,  where  it 
often  pierces  the  tendon  of  the  quadriceps  muscle, 
while  the  lower  fragment  is  felt  in  the  popliteal  space. 
It  is  also  obvious  that  in  T-  or  Y-shaped  fractures  of 
the  lower  third  of  the  shaft  synovitis,  due  to  extravasa- 
tion of  blood  in  the  knee-joint,  is  likely  to  be  caused. 

In  case  of  indentation  of  the  fragments,  an  occur- 
rence that  is  prevalent  in  children,  displacement,  ab- 
normal mobility,  and  crepitus  are  naturally  absent,  but 
there  is  always  present  another  well-marked  symp- 
tom :  namely,  a  pronounced  angle  at  the  seat  of  the 
fracture.  The  same  rule  applies  to  subperiosteal  frac- 
tures of  the  shaft. 

It  may  be  regarded,  therefore,  as  an  exception  when 
fractures  of  the  femur  can  not  be  diagnosticated  by 
simple  inspection.  Consequently,  the  patient  can 
usually  be  spared  the  painful  manipulations  required 
for  eliciting  abnormal  mobility  and  crepitus  at  the  time 
of  the  first  dressinor 

Union  is  generally  perfect  in  six  weeks.  (Fig.  113.) 
In  oblique  fractures  slight  shortening  is  seldom  avoid- 
able ;  but  in  transverse  fractures  the  normal  length  of 
the  leg  can  always  be  preserved.  In  case  of  consider- 
able shortening,  caused  by  vicious  union  (Fig.  114), 
osteotomy  is  indicated. 

Compound  fractures  of  the  shaft  are  so  grave  that 
before  the  time  of  antisepsis  they  showed  a  mortality- 


184 


FRACTURES    OF    SPECIAL    REGIONS. 


Fig.  113. — Union  in  fracture  of  the  middle  of  the  femur  in  a  boy  of  seven 
years  (nine  weeks  after  the  injury).  In  spite  of  the  sideward  displacement  caus- 
ing deformity,  there  is  neither  shortening  nor  functional  disturbance,  which  is 
especially  due  to  the  abundance  of  callus  formation. 


THE  HYGIENE  OF  TRANSMIS- 
SIBLE DISEASES:  their  Causation, 
Modes  of  Dis- 
semination, and 
Methods  of  Pre- 
vention*   By  A. 


ABBOTT  ON 

TRANSMISSIBLE 

DISEASES. 


C  Abbott,  M.D.,  Professor  of  Hygiene 
and  Bacteriology  in  the  University  of 
Pennsylvania ;  Director  of  the  Labora- 
tory of  Hygiene.  Octavo,  285  pages, 
with  Charts,  Maps,  and  numerous  illus- 
trations.    Cloth,  $2.00  net.    J>    £•    J> 

JUST  ISSUED. 

The  prevention  of  disease  is  one  of  the  most 
important  subjects  of  the  day.  With  the  uni- 
versal progress  in  general  education,  the  public 
is  no  longer  satisfied  that  a  physician  enter  the 
house,  prescribe  his  remedies,  and  depart.  They 
desire  more :  they  wish  to  know  the  nature,  the 
origin,  and  the  cause  of  the  sickness,  the  most 
likely  channels  through  which  the  disease  is 
contracted,  and  the  most  suitable  means  for 
preventing  its  recurrence  or  spread.  This  im- 
portant and  necessary  information  the  present 
volume  seeks  to  supply.  It  deals  with  just 
that  practical  portion  of  the  subject  which  is  of 
vital  interest  to  every  intelligent  man  who 
has  at  heart  his  own  best  interests  as  well  as 
those  of  the  community  of  which  he  forms  a 
part.     «£*     ze*     zc*    v*     t£*     &^»     <&     t&     &7*    t£* 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price.  t 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


ANOMALIES  AND  CURIOSITIES 
OF  MEDICINE.  By  George  M. 
Gould,  A.M.,M.D., 


GOULD  AND         and  Walter  L.  Pyle, 

A.M.,  M.D.     Im- 
CURIOSITIES  ; 

OF  MEDICINE        P«ial  octavo.     968 

1    pages,  handsomely 

illustrated.  "  Popular  Edition  f  Cloth, 
$3.00  net ;  Half  Morocco,  $4.00  net. 

An  encyclopedic  collection  of  rare  and  extra- 
ordinary cases,  and  of  the  most  striking  instances 
of  abnormality  in  all  branches  of  medicine  and 
surgery,  derived  from  an  exhaustive  research  of 
medical  literature  from  its  origin  to  the  present 
day,  abstracted,  annotated,  classified,  and  in- 
dexed.   As  a  complete  and  authoritative  Book 


"  A  most  remarkable  and  interesting  volume. 
It  stands  alone  among  medical  literature,  an 
anomaly  on  anomalies.  It  is  a  book  full  of  reve- 
lations from  its  first  to  its  last  page,  and  cannot 
but  interest  and  sometimes  almost  horrify  its 
readers." — American  Medico-Surgical  Bulletin. 

"One  of  the  most  valuable  contributions  ever 
made  to  medical  literature.  Every  page  is  as 
fascinating  as  a  novel."— Brooklyn  Medical  Jour- 
nal. 


of  Reference  it  will  be  of  value  not  only  to 
members  of  the  medical  profession,  but  to  all 
persons  interested  in  general  scientific,  sociologic, 
and  medicolegal  topics ;  in  fact,  the  absence  of 
any  complete  work  upon  the  subject  makes  this 
volume  one  of  the  most  important  literary  inno- 
vations of  the  day.    <&    <£    <£    ^    <£    <£    <£ 

For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

"w\  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


PELVIS    AND     LOWER    EXTREMITY. 


I85 


rate  of  sixty  per  cent.  Nowadays,  they  usually  heal 
without  reaction  under  the  auspices  of  thorough 
asepsis.  (See  p.  51.)  It  is  only  in  compound  frac- 
tures produced  by  a  very  heavy  weight  (locomotive, 


Fig.  114. — Vicious  union  of  fracture  of  femur,  showing  riding  of  fragments,  in  a 
man  fifty- two  years  of  age  (nine  weeks  after  the  injury). 


large  artillery)  that  life  is  jeopardized.  In  such  cases, 
or  when  large  vessels  and  nerves  are  lacerated,  ampu- 
tation offers  the  only  life-saving  chance. 

The  treatment  consists  in  reposition  by  tension  and 
counterextension.     Indisputably,  a  normal  position  of 


I  86  FRACTURES    OF    SPECIAL    RFC IONS. 

the  fragments  is  attainable  if  the  anterior  superior 
spine  and  the  inner  margin  of  the  patella  and  of  the 
great  toe  are  in  a  straight  line.  For  keeping  the  frag- 
ments in  this  position  Buck's  extension  (from  fitteen 
to  twenty-five  pounds  ;  in  children  a  pound  for  each 
year),  supported  by  coaptation  splints,  is  the  securest 
procedure.  These  splints,  preferably  four  altogether, 
should  be  placed  around  the  fractured  area.  1  hey 
may  consist  of  wood  and  must  be  well  padded,  and 
should  be  fixed  to  the  thigh  by  adhesive  plaster.  Adhe- 
sive plaster  strips  should  next  be  carried  around  the 
knee-joint  up  to  the  point  of  fracture.  Counterextension 
is  easily  accomplished  by  elevating  the  foot  of  the  bed. 

In  children  good  results  can  be  attained  by  vertical 
extension.  Although  the  final  results  reported  of  this 
treatment  are  excellent,  the  author  is  unable  to  per- 
suade himself  to  resort  to  a  method  that  is  sure  to 
cause  so  much  annoyance  to  the  patient.  A  plaster- 
of-Paris  dressing  applied  around  the  abdomen  and 
tlwh  while  forcible  extension  and  counterextension  are 
exercised,  and  supported  by  coaptation  splints,  gives 
the  same  good  result  (Fig.  1 1 6)  ;  while  at  the  same 
time  the  children  can  be  carried  around  in  this  dress- 
ing, and  are  therefore  but  little  confined.  Even  in  the 
quite  unnecessary  event  of  pressure-gangrene  of  the 
integument  of  the  thigh  no  serious  consequences  need 
be  feared,  since  the  muscular  layers  protecting  the 
femur  are  extremely  thick.      (Fig.    115.) 

In  adults  the  ambulatory  dressing  is  advisable.  It 
should  be  applied  from  two  to  seven  clays  after  the 
injury  is  sustained,  under  the  conditions  set  forth  in 
Part  I,  where  also  the  technic  of  application  is  dis- 
cussed. 


PELVIS    AND     LOWER    EXTREMITY 


I87 


The  principle  of  the  ambulatory  dressing  is  based 
upon  that  of  the  old  Thomas  splint.  (See  Fig.  6.) 
The  dressing  is  supported  by  the  tuber  ischii,  so  that 
the  pelvis  is  carried  and   the  leg  simply  hangs  down. 


Fig.  115. — Showing  application  of  abdominal  plaster-of- Paris  dressing  in  frac- 
ture of  the  diaphysis  of  the  femur  in  a  girl  fifteen  months  of  age.  The  discolor- 
ation is  caused  by  copal  varnish. 


The  modus  operandi  of  application  is  the  same  as  that 
in  fracture  of  the  neck  of  the  femur. 

In  case  of  union  in  a  slightly  displaced  position  of 
the  fragments  edema  extending  as  far  as  to  the  toes 


i88 


FRACTURES    OF    SPECIAL    REGIONS. 


is  often  noted.  Weeks  after  perfect  consolidation  has 
taken  place  the  patient  may  limp,  and  a  cyanotic  ap- 
pearance, a  sense  of  frigidity,  and  cold  perspiration 
are  likely  to  disturb  his  equanimity.  Hot  soda  baths 
(a  handful  of  washing  soda  to  a  pail  of  very  warm 
water),    hot   fomentations    overnight,    electricity,   and 


Fig.    Il6. — Abdominal    plaster-of- Paris    dressing    applied    while    extension    and 
counterextension  are  exercised,  the  patient  resting  on  a  hip-  and  shoulder-rest. 


massage  are   indicated  in  this  condition.      Massage  is 
especially  useful  if  there  be  muscular  atrophy. 

If  union  has  taken  place  in  a  faulty  position,  the 
function  of  the  lower  extremity  is  greatly  disturbed. 
It  is  the  angular  type  of  deformity  that  is  prevalent  in 
fractures  of  the  femur,  and  that  is  always  followed  by 
considerable  shortening,  sometimes  to  the  extent  of 
five  or  six  inches,  as  in  the  case  illustrated  by  figure 
114. 


PELVIS    AND     LOWER    EXTREMITY.  1 89 

In  children  the  fresh  callus  yields  to  forcible  bend- 
ing. Thus,  without  refracturing  the  femur  correction 
of  the  deformity  under  anesthesia  is  often  possible. 
In  adults  correction  by  such  a  procedure  is  impossible, 
consolidation  once  having  taken  place.  Then,  if  the 
function  of  the  extremity  is  not  considerably  disturbed, 
a  high  shoe  may  compensate  the  shortening.  But  if 
there  is  much  disturbance  of  function,  osteotomy 
should  be  resorted  to  for  radical  correction. 

Refracturing-  the  deformed  bone  by  pressing  it 
against  the  edge  of  the  table  is  permissible  in  suitable 
cases.  It  has  all  the  advantages  of  the  subcutaneous 
fracture  type  ;  but  in  most  instances  the  degree  of  cor- 
rection obtained  is  insignificant,  the  shortening  espe- 
cially being  but  little  affected. 

In  performing  osteotomy  the  incision  should  be 
made  on  the  convexity  of  the  deformed  area,  which 
must  be  well  exposed  by  an  elevator.  Then  the  line 
of  union  of  the  fragments  is  severed  by  means  of  a 
strong  broad  chisel.  In  old  fractures  it  will  often  be 
necessary,  in  order  to  straighten  the  extremity,  to 
resect  a  wedge  from  the  vertex  of  the  deformed  angle. 
After  a  large  moss  dressing  has  been  applied  the 
extremity  is  put  in  permanent  extension.     (See  p.  49.) 

In  pseitdarthrosis  osteotomy  is  always  indicated,  the 
modus  operandi  being  practically  the  same  as  for 
faulty  union,  as  previously  described.  The  incision  must 
be  long,  and  should  be  made  longitudinally  on  either 
the  outer  or  the  anterior  surface  of  the  thigh.  The 
periosteum  must  be  saved  in  its  entirety,  and  should 
therefore  also  be  incised  in  the  longitudinal  direction 
only.  After  all  the  intervening  tissue  has  been  pushed 
aside  or  eventually  removed,  the  bone-ends  are  fresh- 


190 


FRACTURES    OF    SPECIAL    REGIONS. 


ened  and  united  with  strong  silver  wire.  Under  the 
most  minute  aseptic  precautions,  osteotomy,  be  it  done 
for  faulty  union  or  for  pseudarthrosis,  is  an  absolutely 
safe  operation.     (Compare  aseptic  rules,  page  52.) 

Ankylosis  (which  is  generally  due  to  inflammatory 
processes  of  long  duration)  produced  by  comminuted 
fractures  extending  into  the  knee-joint  is  easily  relieved 
by  forcible  motion  under  anesthesia,  provided  it  exists 
for  a  short  period  only  and  is  of  a  fibrous  nature  ;  but 
if  it  be  of  an  osseous  character,  any  attempt  at  forci- 
ble  motion   may   be  followed   by  fatal   consequences. 


/•>  "r 


Fig.  117. — Epiphyseal  separation  of  lower  end  of  femur,      a.   Complete;  b,  in- 
complete. 


Only  an  osteotomy  performed  according  to  the  rules 
set  forth  in  Part  I  of  this  book  could  remedy  this  con- 
dition. In  cases  of  lone  standing-,  however,  where 
other  pathologic  changes  of  the  knee-joint  have  devel- 
oped (fibrous  degeneration,  atrophy,  etc.),  and  where 
the  function  of  the  extremity  is  not  too  seriously  im- 
paired, operative  interference  is  better  dispensed  with. 
(Compare  Fig.  119.) 

Epiphyseal  separation  of  the  lower  end  of  the  femur 
(Fig.  117)  also  deserves  mention.   It  is  either  complete 


PELVIS    AND     LOWER    EXTREMITY. 


I9I 


(Fig.  117  a)  or  incomplete  (Fig.  117  6),  is  not  infre- 
quent at  about  the  age  of  sixteen  years,  and  is  mainly 
observed  in  boys.  Its  principal  cause  is,  however, 
overtraction  during  an  obstetric  operation.  Some- 
times it  is  also  produced  by  excessive  violence,  as,  for 
instance,  by  having  the  limb  entangled  in  a  revolving 
wheel.    As  a  rule,  it  shows  some  displacement.    There 


Fig.  118. — Normal  knee-joint.  A.  Anterior  view  in  a  boy  twelve  years  of 
age ;  note  the  epiphyseal  cartilages  ;  patella  represented  by  a  faint  shade  only. 
B.   Side  view  in  a  man  thirty  years  of  age. 


is  always  abnormal  mobility  and  soft  crepitus.  The 
epiphysis  can  generally  be  palpated  in  its  displaced 
position.  In  the  knee-joint  extravasation  to  a  greater 
or  less  extent  is  always  found.  Pressure  and  ulcera- 
tion may  lead  to  secondary  hemorrhage,  and  thrombo- 
sis may  favor  gangrene.  The  principles  of  treatment 
are  the  same  as  those  for  the  fracture   of  the   lower 


I92  FRACTURES    OF    SPECIAL    REGIONS. 

third  of  the  femoral  shaft.      In  case  the  epiphysis  can 
not  be  replaced,  excision  is  indicated. 

Intra=articular  separation  in  the  knee  still  remains  to  be 
mentioned.  It  consists  either  in  a  rupture  of  the  semi- 
lunar cartilages  or  in  the  severing  of  a  piece  of  the 
femoral  end. 

Rupture  of  the  semilunar  cartilages  is  caused  by 
extensive  rotation  of  the  femoral  end  while  the  knee 
is  flexed  (foot-ball  game). 

The  signs  are  the  presence  of  a  movable  body  in 
the  joint,  which  disappears  during  flexion  and  becomes 
noticeable  during  extension. 

The  treatment  consists  in  reposition,  if  possible,  and 
immobilization  by  a  plaster-of-Paris  dressing  in  exten- 
sion. In  obstinate  cases  extirpation  of  the  severed 
cartilage  is  indicated. 

Intra=articular  severing  of  a  piece  of  the  femoral  end 
is  caused  by  extreme  compression  of  the  bones  of  the 
knee  while  the  latter  is  in  flexion.  The  severed  piece 
moves  freely  in  the  joint  (joint-mouse). 

The  signs  are  similar  to  those  of  the  rupture  of  the 
semilunar  cartilages. 

The  treatment  consists  in  the  immediate  removal  of 
the  cartilage. 

To  appreciate  the  significance  of  the  various  frac- 
ture types  within  the  sphere  of  the  knee-joint,  it  is 
necessary  to  understand  the  peculiar  anatomic  rela- 
tions of  the  knee. 

In  the  first  place,  it  must  be  considered  that  the 
knee-joint  consists  of  the  femoral  condyles,  the  tibial 
head,  and  the  patella,  which  form  three  different  articu- 
lations:  viz.,  one  between  each  tuberosity  of  the  tibia 
on   one   side    and  between   each   femoral  condyle  on 


PELVIS    AND     LOWER    EXTREMITY.  1 93 

the  other,  and  one  between  the  femur  and  the  patella. 
These  articulations  permit  of  extension,  flexion,  and  a 
moderate  degree  of  rotation.  The  tibiofemoral  articu- 
lations are  true  condyloid  joints,  while  the  femoro- 
patellar  articulations  are  only  of  a  partly  arthroidal 
character,  their  mutual  joint-surfaces,  in  fact,  not  being 
adapted  to  each  other.      (Fig.  118.) 


PATELLA. 

Fractures  of  the  patella  amount  to  two  per  cent,  of 
all  fractures,  and  are  far  more  frequent  in  the  male 
than  in  the  female.  They  seldom  occur  after  the  age 
of  fifty,  and  never  in  young  children. 

Fracture  of  the  patella  may  be  produced  by  direct 
as  well  as  by  indirect  violence.  If  produced  by  direct 
violence  (blow  on  the  anterior  bone-surface,  fall  on  the 
anterior  portion  of  the  knee-joint,  kick  of  a  horse), 
the  soft  tissues  in  the  immediate  neighborhood  are 
generally  more  involved  than  the  patella  itself.  The 
line  of  fracture  may  be  transverse,  oblique,  or  longi- 
tudinal, and  its  character  may  be  compound  or  com- 
minuted.     (Fig.  120  a  and  b.) 

If  produced  by  indirect  violence  (muscular  action), 
a  transverse  fracture  is  always  caused,  contraction  of 
the  quadriceps  muscle  fixing  the  patella  while  extreme 
flexion  in  the  knee  takes  place.  So,  for  instance,  if  a 
patient  attempts  to  save  himself  from  falling  while 
making  a  misstep,  by  simple  reflex  the  quadriceps  is 
suddenly  fixed  and  the  knee-joint  is  kept  in  extreme 
flexion. 

The  signs  of  fracture  of  the  patella  are,  in  the  first 
place,  the  separation  diastasis  of  the  fragments  (Figs. 
13 


194  FRACTURES    OF    SPECIAL    REGIONS. 

121  and  122),  the  upper  one  being  drawn  upward  by 
the  action  of  the  quadriceps  muscle.  (Fig.  123.)  The 
sulcus  produced  by  the  diastasis  is  sometimes  as  wide 
as  two  fino-ers'  breadth. 

The  posterior  patellar  surface  forming  a  part  of  the 
knee-joint,  it  is  obvious  that  there  is  always  more  or 
less  considerable  extravasation  in  the  knee-joint. 

It  is  usually  taught  that  the  disturbance  of  function 


Fig.  119. — Bony  ankylosis  of  knee  in  a  woman  thirty-five  years  of  age. 

may  not  be  excessive  so  long  as  the  patient  is  in  an 
upright  position,  but  that  as  soon  as  an  attempt  at 
walking  is  made,  the  patient  would  invariably  tumble 
down.  But  the  author's  experience  shows  cases  in 
which,  in  spite  of  considerable  diastasis,  patients  were 
able  to  walk  considerable  distances  without  apparent 
discomfort.      (Compare  remarks  on  Fig.  123.) 


PELVIS    AND     LOWER    EXTREMITY. 


195 


If  the  injury  be  examined  just  after  the  fracture  is 
sustained,  crepitus  is  generally  produced,  but  after- 
ward the  intervention  of  blood-clots  between  the  frae- 
ments  prevents  its  production. 

If  the  periosteal  coat  of  the  patella  is  preserved 
intact,  there  is  no  displacement,  and  consequently  no 
crepitus.  The  same  rule  holds  good  in  fracture  of  a 
small  portion  of  the  patella. 

It  is  evident  that  in  case  of  extreme  extravasation, 
when,  for  instance,  the  prepatellar  bursae  are  also  well 
filled  up,  palpation  of  the  fragments  becomes  so  very 


Fig.  120. — Types  of  comminuted  patellar  fracture. 


difficult    that  the  injury  may  be  mistaken  for  contu- 
sion of  the  knee-joint. 

With  few  exceptions  union  in  transverse  fracture  of 
the  patella,  if  not  sutured,  fails  to  become  osseous, 
fibrous  bands  filling  up  the  space  between  the  frag- 
ments. This  is  obviously  due  to  the  diastasis.  In 
such  an  event  the  function  of  the  joint  is  impaired — 
inability  to  perform  extension  and  thorough  flexion, 
considerable  atrophy  of  the  muscles  of  the  leg,  and  a 
greater  or  less  degree  of  knock-knee  being  the  pre- 
dominating symptoms.  While  those  who  follow  a 
light  occupation   may  not  be  incapacitated,  and  may 


ig6 


FRACTURES    OF    SPECIAL    REGIONS. 


do  well  by  wearing  a  knee-cap,  workingmen  may  be 
deprived  of  their  means  of  making  a  living  by  such 
impairment. 

In  the  longitudinal  (compare  Fig.  1 20  a)  or  com- 
minuted fracture  type,  where  no  muscular  contraction 
produces  any  diastasis  of  the  fragments,  the  union  is 
always  osseous. 

Cases  of  extreme  extravasation  show  a  great  ten- 
dency  to  the  formation  of  serous  intra-articular  effusion 
(hydrarthrosis). 


Fig.  121.  —  Fracture  of  patella.     Outer  view. 


The  treatment  in  longitudinal  or  in  partial  frac- 
tures of  the  patella  consists  in  bringing  the  fragments 
into  apposition  and  in  proper  immobilization  by  splints 
or  a  plaster-of-Paris  dressing.  Sometimes  reposition 
can  be  accomplished  only  after  the  blood  extravasation 
has  been  removed  by  massage.  If  the  exudate  be  con- 
siderable, its  puncture  and  its  removal  by  irrigation 
with  a  hot  normal  salt  solution  may  become  necessary. 

This  must  be  done  under  the  most  rigorous  aseptic 
precautions. 


PELVIS    AND     LOWER    EXTREMITY. 


197 


Regarding  the  immense  importance  of  such  precau- 
tions, the  following  points  may  be  emphasized  in  this 
connection  : 

In  the  first  place,  it  must  be  considered  that  an  in- 


Fig.  122. — Fracture  of  patella,  showing  moderate  degree  of  diastasis,  in  a  woman 
of  thirty-three  years  (sixteen  hours  after  the  injury). 


jection   has  the  dignity   of  a  surgical  operation,  and 
should   therefore    be   viewed    from  a  strictly  surgical 


I98  FRACTURES    OF    SPECIAL    REGIONS. 

standpoint.  Especially  should  it  be  preceded  by  the 
same  preliminary  precautions  :  viz.,  sterilization  of  the 
puncturing  apparatus  (trocar  or  aspirator),  of  the 
hands  of  the  surgeon,  and  of  the  region  to  be  punc- 
tured. 

As  far  as  the  first    point — the  apparatus — is    con- 
cerned, it  can  be  safely  maintained  that  ideal  asepsis 


Fig.  123. — Fracture  of  patella  in  a  man  twenty-six  years  of  age,  who  walked 
around  for  one  week  without  being  treated.  Motion  was  but  slightly  arrested; 
pain  almost  absent  (eight  days  after  the  injury). 

has  become  an  established  fact,  because  all  objects 
that  stand  boiling  well  can  be  rendered  aseptic  in 
boiling  water,  a  means  accessible  everywhere.  There 
is  no  more  excuse  for  a  surgeon  to  claim  that  "  the 
poor  circumstances  of  the  patient's  surroundings  did 
not  permit  of  aseptic  precautions."  Water,  fire,  and 
a  boiling-pot  can  be  obtained  in  the  poorest  hut, 
so  that  the  puncturing  trocar  can  easily  be  sterilized. 


PELVIS    AND     LOWER    EXTREMITY.  1 99 

Since  syringes  are  so  constructed  that  they  stand 
boiling-  in  a  soda  solution,  the  same  applies  to  them. 
Ordinary  hypodermic  syringes  should  never  be  used 
for  the  purpose  of  aspiration,  because  they  do  not 
stand  boiling  without  being  injured,  nor  do  they  draw 
thick  fluid.  Another  objection  to  them  is  that  their 
thin  needles  break  easily  if  they  have  to  be  pushed 
deep  down  into  resistant  tissues. 

As  far  as  the  hands  of  the  surgeon  and  the  region 
to  be  punctured  are  concerned,  the  general  rules  em- 
phasized in  connection  with  the  treatment  of  compound 
fractures  are  referred  to.     As  mentioned  on  page  56, 
that  enemy  of   thorough  asepsis,  intracutaneous  bac- 
teria,  should  not   be    underrated    in    connection  with 
the   question  of  puncturing.     It  is  evident  that  in  per- 
forating the  skin  the  sterilized  puncturing  needle  must 
come  in  contact  with  the  deep  skin-bacteria,  which  are 
sheltered  by  the  follicles  of  the  integument,  and  must 
thus  become   a  carrier  of  infection.      It  is  an  undeni- 
able fact  that  these  intracutaneous  bacteria  can  not  be 
destroyed  by  any  chemic  or  mechanical  means  of  dis- 
infection.    Still,  a  great  deal   can   be  done   to  lessen 
the  danger  of  infection  by  this  source.     Fortunately, 
we  possess  a   splendid   permeating  antiseptic   in   the 
tincture  of  iodin,  which,  if  liberally  used,  reaches  the 
bacterial  shelter — the  glands.     It  is  true  that,  as  the 
bacteriologic  experiments  of  the  author  have  shown, 
not  all   intracutaneous  bacteria  are  destroyed  by  the 
tincture,   cultures  having  developed   on  artificial  soil. 
But  they  failed  to  develop  on  an  unfavorable  soil.     It 
is  safe,  therefore,  to  assume  that  if  the  surface  of  the 
skin    is   cleaned    according   to   the   aseptic    rules   laid 
down  on  page  52,  and  the  region  of  the  area  to  be 


200  FRACTURES    OF    SPECIAL    REGIONS. 

punctured  is  painted  with  iodin  tincture,  a  sterilized 
instrument  in  sterilized  hands  will  hardly  carry  bac- 
teria into  the  joint-cavity. 

In  transverse  fractures  of  the  patella  showing  little 
or  no  diastasis,  a  plaster-of-Paris  dressing  is  applied 
according  to  the  principles  laid  down  for  fracture  of 
the  olecranon.     (Seep.  125.) 

While  the  displaced  fragment  is  tightly  grasped  and 
pushed  downward  by  the  fingers  of  an  assistant,  the 
dressing  is  applied.  The  limb  is  best  put  in  the  hyper- 
extended  position,  while  the  patient  sits  in  bed  half 
upright.  The  turns  of  the  bandage  are  conducted 
around  the  pressing  fingers,  so  that  at  last  a  wall  is 
formed  around  the  digital  impressions,  which  includes 
the  reduced  fragments  after  the  plaster  sets,  and  be- 
comes so  firm  that  a  return  of  the  fragments  proves  to 
be  impossible. 

But  if  there  is  considerable  diastasis,  wiring  of  the 
fragments  can  not  too  strongly  be  advocated,  since  the 
performance  of  this  simple  operation  is  void  of  danger 
in  the  hands  of  a  surgeon  who  is  master  of  the  princi- 
ples of  asepsis.  Whatever  has  been  said  of  the  dan- 
gers of  this  operation  applies  more  to  the  surgical 
novice,  who  does  not  properly  understand  asepsis,  than 
to  aseptic  surgery  itself.  When  it  is  considered  that 
without  such  operation  union  becomes  only  fibrous, 
and  that  in  the  course  of  time  the  originally  fibrous 
bands  become  stretched  by  the  action  of  the  quadri- 
ceps muscle,  so  that  active  extension  of  the  knee- 
joint  becomes  impossible, — in  other  words,  that  the 
patient  becomes  a  cripple  for  life, — we  should  not 
refrain  from  exposing  the  patient  to  the  trouble  of  this 
operation,  which  guarantees  an  absolute  cure. 


PELVIS    AND     LOWER    EXTREMITY. 


20I 


Complicated  manceuvers,  like  boring-  holes  into  the 
fragments,  etc.,  can  not  be  too  strongly  condemned, 
since  simply  conducting  a  large  needle  armed  with 
silver  wire  around  the  fragments  secures  their  perfect 
apposition.  The  needle  must  be  introduced  at  the 
upper  end  into  the  quadriceps  tendon  above  the 
patellar  margin  and  through  the  ligamentum  patellae 


Fig.  124. — Wiring  of  the  patella:  placing  the  silver  wire  around  the  frag- 
ments. Each  of  the  two  black  semilunar  points  represents  a  patellar  fragment. 
The  white  egg-shaped  area  between  the  patellar  fragments  belongs  to  the  anterior 
surface  of  the  external  femoral  condyle. 


on  the  lower  margin  of  the  lower  fragment.  (Fig. 
124.)  The  silver  wire  is  twisted  above  the  middle  of 
the  fracture  line,  its  ends  protruding  at  last  through  the 
suture  line  of  the  integument.     (Fig.   125.) 

A  semilunar  incision  should  be  made  from  one  epi- 
condyle  to  the  other,  just  above   the   insertion  of  the 


202 


FRACTURES    OF    SPECIAL    REGIONS. 


ligamentum  patellae.  Thus  a  convex  flap  is  formed, 
which  is  dissected  backward.  The  fractured  area  is 
then  fully  exposed,  and  the  intra-articular  blood  extra- 
vasation can  be  freely  reached. 

An  iron-clad  principle,  especially  referring  to  this 
operation,  is,  "  Hands  off  the  joint  !  " 

For  the  consolation  of  such  suroeons  as  are  afraid 


Fig.  125. — Patellar  fragments  (Fig.  124)  united  by  a  silver  wire  suture. 

of  the  aseptic  state  of  their  own  fingers  it  may  be  said 
that  there  is  no  need  for  coming  into  contact  with  any 
portion  of  the  field  of  operation  with  their  fingers  or 
hands.  The  needle  can  be  carried  through  with  the 
aid  of  a  needle-holder  and  the  twisting,  which  in  itself 
tends  to  bring  the  fragments  together,  can  be  done 
with  a  forceps.  The  blood-clots  can  be  removed  by 
powerful  irrigation  with  a  hot  sterile  salt  solution. 


PELVIS    AND    LOWER    EXTREMITY.  203 

For  powerful  and  thorough  irrigation,  intended  for 
the  mechanical  removal  of  such  material  as  may  be 
apt  to  offer  a  favorable  soil  for  the  development  of 
bacteria  (tissue-shreds,  blood-clots),  an  operating-table 
(Fig.  5)  that  is  provided  with  pans  is  of  great  conve- 
nience. 


Fig.  126. — Wire  broken  three  weeks  after  the  operation,  the  nervous  patient  having 
jumped  out  of  bed  during  the  night.      Immediate  recurrence  of  diastasis. 


After  the  suturing  (preferably  done  with  boiled  for- 
malin catgut)  is  completed,  either  an  ordinary  wound 
dressing,  supported  by  a  large  moss  splint,  or  a  fenes- 
trated plaster-of-Paris  dressing  (the  fenestra  being 
created  by  holding  a  sterilized  glass  over  the  wound — 


204  FRACTURES    OF    SPECIAL    REGIONS. 

see  Fig.  5)  is  applied.  The  wire  suture  is  carefully 
removed  after  three  weeks.  Then  the  knee  is  well 
immobilized  for  two  or  three  weeks  longer,  and  the 
patient  is  allowed  to  walk  about  in  this  dressing. 

The  wire  must  be  very  strong,  for  there  is  risk  of  its 
breaking  if  the  patient  be  restless.  (Fig.  126.)  The 
operation  can  be  performed  immediately  after  the  acci- 
dent, but  may  just  as  well  be  deferred  for  a  few  days 
if  extravasation  is  abundant. 

In  view  of  the  absolute  certainty  of  success  in  this 
operation,  the  principle  of  which  was  advanced  by  one 
of  the  greatest  surgical  geniuses  of  all  time,  Volkmann, 
it  appears  rather  strange  that  procedures  like  the  treat- 
ment with  Malgaigne's  hook,  which  remind  one  of  the 
relics  in  the  torture  chambers  of  Nuremberg,  still  find 
their  devoted  partizans. 

Compound  fractures  of  the  patella  are  treated  after 
the  same  principles  as  are  set  forth  in  Part  I.     (P.  51.) 

In  the  event  of  atrophy  of  the  quadriceps  muscle, 
which  is  extremely  frequent  after  the  non-operative 
treatment  of  the  patellar  fracture,  faradization  and 
massage  are  indicated  for  a  lone  time. 


LEG. 

It  is  assumed  that  fractures  of  the  leg  constitute 
about  sixteen  per  cent,  of  all  fractures.  They  occur 
predominantly  between  the  ages  of  thirty  and  sixty, 
but  are  rare  in  childhood. 

Some  of  our  former  views  on  fractures  of  the  leg 
were  also  radically  shaken  by  the  Rontgen  rays,  and 
most  of  our  knowledge  had  to  be  greatly  modified. 
As  in  fractures  of  the  lower  end  of  the  radius,  fissures 


PELVIS    AND     LOWER    EXTREMITY.  205 

and  fractures  that  formerly  were  entirely  unknown 
were  found  to  be  of  frequent  occurrence.  Fissures 
as  well  as  comminuted  infractions  had  been  overlooked 
in  the  pre-R6ntgen  era,  because  they  showed  no  ten- 
dency to  displacement.  Another  essential  point  re- 
vealed by  the  Rontgen  rays  is  that  in  many  instances 
the  injury  itself,  and  particularly  the  extent  of  the 
displacement,  was  much  more  serious  than  was  to  be 
expected  from  ordinary  means  of  examination  or  by 
judging  from  the  degree  of  the  deformity. 

They  are  classified  best  as  epiphyseal  separation, 
simultaneous  fracture  of  the  tibia  and  fibula,  and  frac- 
ture of  either  tibia  or  fibula  individually. 

Epiphyseal  separation  is  observed  in  individuals 
under  twenty.  The  etiology,  signs,  and  treatment  of 
this  injury  fall  under  the  same  considerations  as  those 
of  the  fractures  of  the  same  type,  so  that  a  separate 
description  seems  unnecessary. 

Separation  of  the  tubercle  of  the  tibia,  sometimes 
occurring  in  children,  is  treated  on  the  same  principles 
as  fracture  of  the  patella,  for  which,  moreover,  it  is, 
as  a  rule,  mistaken. 

Simultaneous  fractures  of  the  tibia  and  fibula 
are  subdivided  into  fractures  of  the  upper  and  middle 
portions  and  into  fracture  of  the  lower  end. 

Simultaneous  fractures  of  the  tibia  and  fibula  at  their 
upper  and  middle  portions  are  generally  produced  by 
direct  violence  (passage  of  a  wagon-wheel,  falling  of 
a  heavy  weight,  kick  of  a  horse).  The  predilection  is 
for  the  middle  third,  while  the  upper  portion  is  but 
rarely  involved.  It  is  less  frequent  in  children  than 
fracture  of  the  femur. 

If  produced  by  indirect  violence  (fall  from  a   high 


206  FRACTURES    OF    SPECIAL    REGIONS. 

point,  misstep  on  slippery  ground),  the  fracture  of 
the  tibia  is  always  below  that  of  the  fibula,  the  tibia 
being-  broken  first  and  the  fibula  then  giving  way 
higher  up. 

The  line  of  fracture  is  generally  oblique  or  spiral, 
the  transverse  variety  being  found  but  exceptionally. 
Indentation  is  a  frequent  occurrence. 

Compound  fractures  are  extremely  common  in  this 
sphere,  a  fact  well  explained  by  the  situation  of  the  an- 
terior tibial  surface  directly  underneath  the  integument. 

The  signs  are  always  well  marked,  a  circumstance 
also  explainable  by  the  superficial  situation  of  the 
tibia,  whereby  sideward  displacement  is  made  dis- 
tinctly perceptible.  There  is  also  outward  rotation  of 
the  limb  and  an  angular  protrusion  of  the  crest  of  the 
tibia.  The  fibular  fragments  appear  less  conspicuous, 
since  their  protection  by  the  peroneal  muscles  makes 
their  palpation  somewhat  more  difficult.  But  the  short- 
ening and  the  marked  abnormal  mobility  prove  the 
simultaneous  fracture  of  the  fibula  beyond  a  doubt. 

In  the  far  less  serious  event  of  indentation,  dis- 
placement, abnormal  mobility,  and  crepitus  are  natu- 
rally absent,  the  signs  being  limited  to  intense  local 
pain  and  loss  of  function. 

The  treatment  consists  in  reposition  by  extension 
on  the  foot,  which  is  held  rectangularly,  and  by 
counterextension  on  the  knee.  Under  this  manipula- 
tion shortening  disappears  at  once.  Protrusion  of  the 
upper  fragment  is  counteracted  by  elevating  the  heel 
in  order  to  draw  the  lower  fragment  downward  and 
forward.  Still  more  effectual  is  counterpressure  exer- 
cised by  a  weight,  which  should  be  attached  to  the  area 
of  the  upper   fragment.      If  the  inner  margin   of  the 


PELVIS    AND     LOWER    EXTREMITY 


207 


patella  is  in  line  with  the  inner  side  of  the  ball  of  the 
great  toe,  the  position  is  correct. 

The   best    chances    for    keeping    the    fragments    in 
proper  apposition    are  offered  by  the   plaster-of-Paris 


A. 


Fig.  127. — Fracture  of  diaphysis  of  tibia  and  fibula.  A,  Pseudarthrosis 
relieved  by  wiring;  wire  of  tibial  fragments  still  in  situ  :  B,  non-union,  fragments 
wired  three  months  after  the  injury. 


dressing,  which  is  applied  while  extension,  counterex- 
tension,  and  counterpressure  are  exercised.  (Compare 
Figs.  5,  116.)  If  padding  is  well  done,  there  is  no  fear 
of  the  supervention  of  pressure  gangrene.  If  the  case 
can   not  be  kept  under  daily  control,  and  especially  if 


208  FRACTURES    OF    SPECIAL    REGIONS. 

the  patients  be  unintelligent,  or  if  there  be  much  ten- 
sion and  swelling,  splints  are  preferable. 

The  ambulatory  dressing  (compare  Fig.  6),  in  which 
the  patient  can  walk  about  on  crutches,  can  be  applied 
after  from  four  to  seven  days.     The  modus  operandi 


Fig.  128. — Supramalleolar  fracture  in  a  man  fifty-eight  years  ot  age. 
Although  displacement  was  apparently  slight,  filling-up  of  the  interosseal  space 
causes  great  functional  disturbance  (two  years  after  the  injury). 

consists  in  applying,  after  the  skin  is  well  oiled,  a  solid 
plaster-of-Paris  dressing  from  the  metatarsus  up  to  the 
lower  third  of  the  thigh.  The  support  is  furnished  by 
the  femur  and  its  condyles.  The  sole  of  the  dressing 
is  fortified  by  inlaying  with  strips  of  tin,  zinc,  or  wood. 


PELVIS    AND     LOWER    EXTREMITY.  200, 

It  is  amazing-  how  many  fractures  of  the  leg,  even  in 
these  clays,  heal  with  more  or  less  deformity.  Pseudar- 
throsis  (Fig.  127,  A)  and  non-union  (Fig.  127,  B)  are 
also  frequent  occurrences.  In  the  latter  event  oste- 
otomy must  be  performed.  In  children,  in  whom  the 
injury  is  often  the  result  of  being  run  over,  the  corn- 


Fig.  129. — Supramalleolar  fracture  combined  with  infraction  of  fibula  in  a 
woman  seventy  years  of  age,  showing  moderate  displacement.  Function  perfect 
(four  weeks  after  the  injury). 

pound  variety  is  prevalent.  Still,  the  most  unfavorable 
cases  have  an  astonishing  tendency  to  heal  under  care- 
ful observation  of  aseptic  principles.      (See  p.  52.) 

Simultaneous  fractures  of  the  loiver  end  of  the  tibia 
and  fibula  are  either  supramalleolar  or  malleolar. 

(a)  Supramalleolar  fracture  (Figs.  128,  129,  and 
14 


2IO 


FRACTURES    OF    SPECIAL    REGIONS. 


130)  of  the  bones  of  the  leg  is  produced  by  direct  as 
well  as  by  indirect  violence,  the  lines  of  fracture  running 
into  the  ankle-joint  in  the  majority  of  cases.  This  type 
is  analogous  to  the  supracondylar  fracture  of  the  femur 
and  humerus,  and  is  generally  of  a  severe  character. 


Fig.  130. — Supramalleolar  fracture  in  a  man  forty-two  years  of  age,  showing 
considerable  displacement.  The  interosseous  space  is  filled  up  with  displaced 
fragments,  which  cause  great  functional  disturbance  (four  months  after  the  injury). 

The  signs  are  very  well  marked,  displacement  being 
the  most  prominent  one. 

The  treatment  consists  in  reposition  and  immobiliza- 
tion by  wire  splints,  molded  after  the  shape  of  the 
foot  and  leg,  or  by  a  well-padded  plaster-of- Paris  splint. 


PELVIS    AND     LOWER    EXTREMITY. 


21  I 


Reposition  is  much  more  difficult  then  than  that  of  the 
well-known  simple  malleolar  fracture.  Anesthesia  can 
but  rarely  be  dispensed  with.  If  a  plaster-of-Paris 
dressing  is  applied,  thorough  revision  must  be  per- 
formed at  least  once  a  week.  Massage  treatment 
should  be  commenced  after  two  weeks.  Restoration 
to  perfect  functional  ability  may  not  take  place  for  a 
year.  If  the  interosseous  space  is  free,  no  functional 
disturbances  may  be  present  even  in  cases  of  deformed 


Fig.  I31. — Malleolar  fracture. — (After  Hoffa). 

union.  (Fig.  129.)  But  if  the  interosseous  space  is 
filled  up  with  displaced  fragments  and  abundant  callus 
(Fig.  130),  osteotomy  will  be  indicated. 

(b)  Malleolar  fracture,  usually  called  Pott's  fracture 
(Fig.  131),  is  generally  caused  by  the  body  being  bent 
down  and  outward  while  the  foot  is  kept  fixed. 

This  type  is  analogous  to  the  fracture  of  the  lower 
end  of  the  radius,  the  strong  ligamentum  carpi  volare 
profundum  of  which  never  breaks.      The  ligamentous 


212 


FRACTURES    OF    SPECIAL    REGIONS. 


connection  of  the  tibia  with  the  fibula  is  so  strong 
that  its  fracture  is  generally  followed  by  the  break  of 
its  fellow.  In  the  corresponding  typical  fracture  of 
the  radius  the  ulna  does  not  always  follow  the  ex- 
ample of  its  fellow,  but,  as  emphasized  in  the  section 


Fig.  132. — Malleolar  fracture  in  a  woman  thirty -six  years  of  age,  showing  a 
long  oblique  splinter  separated  from  the  external  malleolus  and  a  small  fragment 
detached  from  the  internal  malleolus  (ten  days  after  the  injury). 


on  Radial  Fracture  (p.  153),  in  many  instances  it  be- 
comes infracted. 

Among  the  signs  the  most  prominent  one  is  a  very 
well-marked  displacement,  the  direction  of  which  is 
generally  sidewise.  It  should  be  borne  in  mind  that 
if  the  fracture  extends  over  only  a  small  portion  of  the 
malleoli,  the  function  of  the  leg  may  be  so  little  dis- 


PELVIS    AND     LOWER    EXTREMITY.  213 

turbed  that  the  patient  is  able  to  walk  considerable 
distances ;  and  if  the  examination  be  not  thorough, 
contusion  or  distortion  may  be  erroneously  diagnos- 
ticated— as,  for  instance,  in  the  case  illustrated  by 
figure  132.  (Also  compare  remarks  on  Fracture  of 
the  External  Malleolus,  p.  224.) 

The  extravasation  beino-  sometimes  considerable,  it 
can  be  understood  that  in  many  instances  but  little 
displacement  is  shown.  In  such  cases  palpation 
always  reveals  the  presence  of  the  fracture.  Crepitus 
is  also  seldom  absent.  Taking  into  consideration  its 
close  relation  to  the  ankle-joint,  it  is  easily  understood 
that  this  injury  represents  a  severe  fracture  type.  In 
fact,  there  is  a  great  tendency  to  deformity  as  well  as 
to  the  development  of  a  severe  form  of  arthritis. 

It  has  been  the  author's  experience  that,  especially 
in  childhood,  inflammatory  processes  of  the  ankle-joint 
were  not  infrequently  mistaken  for  old  malleolar  frac- 
tures. This  may  appear  strange  at  first  sight ;  but  in 
view  of  the  fact  that  tuberculosis  in  this  region  often 
develops  after  slight  injuries,  it  is  not  unnatural  that  the 
swelling  caused  by  the  tubercular  process  should  be 
mistaken  for  a  deformity  following  fracture. 

In  osteomyelitis  a  preceding  subcutaneous  trauma  is 
also  often  reported.  The  intense  pain,  the  edema,  the 
fever,  and  the  general  debility,  as  a  rule,  so  significant 
for  osteomyelitis,  may  be  sometimes  so  little  marked 
that  differentiation  becomes  difficult.  Figure  142 
illustrates  this  possibility.  In  this  case  an  anemic  girl, 
eleven  years  of  age,  sustained  an  apparently  slight  in- 
jury by  falling  on  the  street.  There  was  moderate 
pain  and  slight  swelling  around  the  ankle-joint,  which 
was  regarded  as  a  sprain  until  the  swelling  gradually 


2  14  FRACTURES    OF    SPECIAL    REGIONS. 

extended.  It  was  then  assumed  that  there  had  been  a 
fracture,  the  displaced  fragments  of  which  had  caused 
the  swelling,  the  deformity,  and  the  disturbance  of 
function.  A  skiagram,  taken  five  weeks  after  the 
injury,  revealed  the  presence  of  an  osteomyelitic  focus 
at  the  lower  end  of  the  tibia,  and  no  signs  of  a  pre- 
ceding injury  to  the  bone.  The  swelling  not  permit- 
ting thorough  palpation  of  the  malleoli,  the  error  ap- 
pears very  pardonable.  (As  to  etiology  and  differenti- 
ation, compare  case  illustrated  by  Fig.  37 '.) 

The  focus  was  exposed  under  the  guidance  of  the 
skiagram  and  was  extirpated.  The  ease  and  the  secu- 
rity with  which  these  operative  procedures  can  be 
carried  out  under  the  control  of  the  rays  should  be 
emphasized.  Formerly  it  was  deemed  advisable  to 
chisel  up  the  bone  in  its  whole  length  in  order  to  be 
sure  that  every  possible  focus  was  really  reached. 
Now  the  skiagram  dictates  even  the  length  of  the  inci- 
sion necessary  for  a  thorough  removal. 

The  dislocations  in  the  ankle-joint,  which  are  usually 
either  backward  or  forward,  show  such  characteristic 
signs  that  differentiation  should  not  meet  with  any 
difficulty.  The  rare  type  of  subastragalar  dislocation, 
however,  which  is  either  inward  or  outward,  may  be 
confounded  with  a  fracture,  as  long  as  the  Rontgen  rays 
are  not  consulted. 

The  treatment  consists  in  exact  reposition,  which  is 
effected  while  adduction  is  exercised,  the  fibula  being 
forcibly  pressed  against  the  tibia.  To  accomplish  this 
well,  anesthesia  is   required  in  the  majority  of  cases. 

Immobilization  is  kept  up  by  a  plaster-of-Paris  dress- 
ing, which  is  applied  while  the  foot  is  adducted  to  the 
rectangular  position  ;  that  is,  in  a  direction  such  as  the 


PELVIS    AND     LOWER    EXTREMITY. 


21 


planta  pedis  would  normally  assume  in  walking. 
Whenever  the  plaster-of-Paris  dressing  can  not  be 
used,  the  Volkmann  splint  or  the  removable  plaster- 
of-Paris  splint  is  to  be  employed.  Massage  treatment 
should  be  started  two  weeks  after  the  injury.  When- 
ever there  is  such  doubt  as  to  the  significance  of  the 


Fig.  133. — Isolated  frac- 
ture of  tibia  at  its  upper  end 
in  a  girl  three  years  of  age 
(three  weeks  after  the  injury). 


Fig.  i^_ — Fracture  of  the  shaft  of  the  tibia 
in  a  woman  twenty-five  years  of  age,  sustained 
at  the  age  of  five,  after  an  operation  for  necrosis 
of  the  tibia. 


injury  of  the  malleolar  region  that  the  question  can  not 
be  settled  instantly  by  a  Rontgen  apparatus,  the  case 
should  be  treated  as  one  of  severe  fracture. 

Union  is  generally  perfect  in  four  weeks.  Stiffness 
of  the  ankle-joint  and  swelling  of  the  soft  tissues 
continue  often  after  perfect  consolidation.  If  appo- 
sition was  correct,  these  conditions  will  yield  to  forci- 
ble motion  of  the  joint,  local  baths,  and  massage.     In 


2l6 


FRACTURES    OF    SPECIAL    REGIONS. 


the  case  of  union  in  a  perverse  position,  which  is  a 
frequent  result,  osteotomy  is  always  indicated. 

Isolated  Fracture  of  the  Tibia. — Isolated   frac- 


Fig-  135- — Same  case  as  figure  134,  showing  enormous  development  of  the 
greatly  deflected  fibula  and  the  arrest  of  growth  in  the  tibia.  A  new  movable 
joint,  containing  normal  synovial  fluid  and  showing  well-developed  synovial  mem- 
branes, had  formed. 


ture  of  the  tibia  may  take  place  at  its  upper  or  lower 
end,  or  it  may  take  place  through  the  shaft. 

(a)  Isolated  fracture   through  the  upper  end  of  the 
tibia  is  caused  by  direct  as  well  as  by  indirect  violence. 


PELVIS    AND     LOWER    EXTREMITY. 


217 


Injuries  of  this  kind  are  rare.  (Fig.  133.)  They  are 
produced  by  compression.  This  fracture  may  be  due 
to  gunshot  or  to  a  vertical  fall  on  the  foot  (fall 
from  a  bicycle) — other  injuries  generally  producing 
simultaneous  fracture  of  the  fibula.  If  the  line  of 
fracture  is  transverse,  there  is  little  displacement,  the 
fibula  acting  as  a  kind  of  a  side-splint  to  retain   the 


Fig.  136. — Comminuted  fracture  of  the  tibia  caused  by  gunshot  from  fifty  yards' 
distance  (skiagraphed  one  hour  after  the  injury). 


fragments  in  apposition  ;  but  there  is  local  pain,  ec- 
chymosis,  and  a  more  or  less  marked  irregularity  on 
the  anterior  tibial  surface.  If  the  line  of  fracture  is 
oblique,  there  is  more  or  less  lateral  deflection. 

Without  the  aid  of  the  Rontgen  rays,  however,  an 
exact  diagnosis  is  often  impossible. 

In  fracture  of  the  tibia  due  to  necrosis  the  growth 
of  the  bone  may  be  arrested,  as  shown  in  figures  134 


218 


FRACTURES    OF    SPECIAL    REGIONS. 


and    135,   where    the  fibula    had    practically   assumed 
the  function  of  the  tibia. 

The  treatment,  if  there  is  any  displacement,  consists 
in    reposition.      Otherwise    the    treatment   is  identical 


Fig-    137- — Indications  of  oblique   fracture  of  the   left  tibia  failing  to  be  repre- 
sented by  the  Rontgen  rays  in  the  dorsal  position. 


with  that  for  the  simultaneous  fracture  of  the  tibia  and 
fibula. 

(b)  Isolated  fracture  of  the  tibia  through  its  shaft  at 
about  its  middle  may  be  due  to  direct  as  well  as  to 
indirect  violence,  such  as   a  kick,  a  knock,  a  fall,  or  a 


PELVIS    AND     LOWER    EXTREMITY. 


219 


gunshot.    (Fig.  136.)    In  children  infraction  of  the  shaft 
is  often  the  result  of  a  moderate  degree  of  violence. 

(Fig.  138.) 

The  fracture  line  is  sometimes  transverse  ;  in  the 

majority  of  cases  it  is  oblique,   and   if  there   be  but 

little  displacement,  the  diagnosis  of  the  fracture  may 


Fig.  138. — Infraction  of  tibia  in  a  boy  four  years  of  age  (three  hours  after  injury). 


be  difficult  without  the  aid  of  the  Rontgen  rays. 
(Compare  the  history  of  the  case  illustrated  by  Fig. 
139,  a  and  &,  and  described  in  the  section  on  Errors 
in  Skiagraphy.) 

The  treatment  is  the  same  as  that  for  isolated  frac- 
ture through  the  upper  end  of  the  tibia. 

(c)  Isolated  fracture  of  the  lower  end  of  the  tibia 


220 


FRACTURES    OF    SPECIAL    REGIONS. 


(isolated  supramalleolar  fracture)  has  the  same  etiol- 
ogy as  the  simultaneous  fracture  type  described  pre- 
viously, with  the  exception  that  the  force  producing 
it  is  usually  less  violent.  In  childhood  infraction  is 
observed  sometimes  as  illustrated  by  figure  138. 

The  signs  are  not  always  well  marked.     There  being 

A.  B. 


Fig.  139 — Fracture  of  the  tibia.  Same  case  as  figure  137.  A.  Oblique 
type,  in  a  boy  four  years  of  age  (twelve  hours  after  the  injury).  B.  Union 
nearly  perfect  (four  weeks  after  the  injury). 


no  deflection  present,  they  are  limited  to  one  unre- 
liable symptom  only  :  namely,  the  local  pain  and  ten- 
derness, which  could  just  as  well  be  due  to  a  simple 
fissure  or  a  distortion.  (Fig.  140.)  The  Rontgen 
rays,  of  course,  will  never  fail  to  elucidate  the  true 
character  of  the  injury. 

The  treatment  falls    under  the  same  consideration 


PELVIS    AND     LOWER    EXTREMITY. 


221 


as  pertains  to  the  simultaneous  fracture  type.     (Page 
206.) 


Fig.  140. — Spiral  fracture  of  the  lower  third  of  the  tibia  in  a  boy  of  three 
years  (twenty-four  hours  after  the  injury).  (Note  relations  of  the  cartilaginous 
epiphyses  in  the  knee-joint.) 

As  long  as   any  doubt  as  to  the  character  of  the 
injury  exists,  it  should  be   treated  as  a   fracture.      If 


222 


FRACTURES    OF    SPECIAL    REGIONS. 


reposition  has  been  imperfect,  shortening'  of  the  leg 
and  considerable  thickening  of  the  ankle-joint  may 
result.  Atrophy  of  the  muscles  of  the  leg,  varus-  or 
valgus-position,  etc.,  may  prevent  the  patient  from 
walking   normally.      If,  in  case    of   considerable    dis- 


Fig.  141. — Fracture  of  the  lower  end  of  the  tibia  in  a  man  fifty-two  years  of 
age,  showing  considerable  backward  displacement.  Great  functional  disturbance 
(one  year  after  the  injury). 


placement,  reposition  has  been  omitted,  the  tibial 
fragments  may  be  shifted  away  from  their  natural 
relations,  particularly  in  the  articulations  between 
tibia  and  fibula.  This  condition  is  illustrated  by  figure 
141,  which  shows  protrusion  of  the  lower  tibial  frag- 
ment to  an  enormous  extent. 


PELVIS    AND     LOWER    EXTREMITY.  223 

It  goes  without  saying  that  in  such  an  event  the 
function  of  the  ankle-joint  is  greatly  impaired.  When 
consolidation  is  not  perfect  (three  to  five  weeks  after 
the  injury),  there  is  a  chance  for  redressing  the  pro- 
truding fragment  under  anesthesia,  but  later  on  the 
only  remedy  possible  is  offered  by  osteotomy. 

Epiphyseal    separation   of   the   lower  end  is   some- 


Fig.  142. — Osteomyelitic  focus  in  the  lower  end  of  the  tibia,  characterized  by  the 
translucency  of  the  diseased  area. 

times  caused  by  traction  during  labor.  In  connec- 
tion with  fracture  of  the  fibula,  compound  separation 
takes  place  sometimes  in  older  children.  The  treat- 
ment is  the  same  as  that  for  isolated  fibular  fracture. 
Isolated  Fracture  of  the  Fibula  (Fig.  143,  A 
and  B). — The  isolated  fracture  of  the  fibula  generally 
occurs  at  the  lower  third. 


224 


FRACTURES  OF  SPECIAL  REGIONS. 


The  signs  as  well  as  the  treatment  fall  under  the 
same  considerations  as  those  of  the  malleolar  fracture. 

The  fibula  may  also  fracture  at  any  other  point,  but 
such  occurrence  is  extremely  rare.     The  signs  of  the 

A.  B. 


Fig.  143. — A.  Isolated  fracture  of  the  fibula  in  a  man  twenty-nine  years  of 
age  (one  day  after  the  injury).  B.  Isolated  fracture  of  the  fibula,  causing  moder- 
ate functional  disturbance,  in  a  man  forty-two  years  of  age  (three  weeks  after  the 
injury). 


latter  type  are  but  little  marked,  the  only  important 
one  being  represented  by  local  pain. 

The  cause  of  the  fracture  of  the  fibula  at  its  lower 
end,  which  is  also  called  fracture  of  the  external  mal- 
leolus, is  the  same  as  that  of  distortion.  The  outer 
margin  of  the  astragalus  pressing  against  the  external 
malleolus,  while  the  foot  is  bent  in  forced  supination,  it 


PELVIS    AND     LOWER    EXTREMITY.  225 

is  natural  that  the  malleolus  yields  above  the  margin  of 
the  astragalus,  since  the  very  strong  calcaneofibular 
ligament  generally  resists  the  force.  The  comparison 
with  the  mechanism  of  the  fracture  of  the  lower  end 
of  the  radius  is  also  obvious. 

Some  patients  are  able,  after  having  sustained  a 
fracture  of  the  external  malleolus,  to  walk,  and  even 
to  work,  so  that  the  erroneous  diagnosis — distortion — 
is  often  made.  The  author  is  convinced  that  he  has 
committed  this  error  himself  before  he  had  a  chance 
to  avail  himself  of  the  advantages  of  the  Rontgen 
rays. 

If  such  cases  are  consequently  treated  as  distortions 
by  the  application  of  ointments,  fomentations,  etc., 
enormous  callus  formation  of  the  external  malleolus 
and  varus-position  may  be  the  result.  Naturally,  the 
relation  of  the  external  malleolus  to  the  astragalus  is 
influenced  by  the  faulty  position.  The  external  margin 
of  the  foot  exclusively  being  utilized  while  walking,  it 
is  natural  that  the  metatarsal  bones  are  also  shifted 
sideward,  and  finally  even  the  knee  will  participate  in 
the  faulty  position. 

The  treatment  consists  in  simple  immobilization 
(plaster-of-Paris).  The  tibia  acting  as  a  side  splint, 
union  becomes  perfect  under  almost  any  immobilizing 
treatment. 

The  rule  that  osteotomy  must  be  resorted  to  in  case 
the  function  of  the  extremity  is  disturbed  applies  to 
all  the  various  types  of  fractures  of  the  leg  in  which 
union  has  taken  place  in  a  faulty  position,  provided  the 
proper  time  for  bloodless  redressement  has  elapsed. 
The  modus  operandi  is  practically  the  same  as  that 
described  for  osteotomy  of  the  femur — that  is,  chisel- 
15 


2  26        FRACTURES  OF  SPECIAL  REGIONS. 

ing  off  of  protruding  or  intervening  fragments,  or 
severing  the  displaced  fragments  entirely  by  means  of 
a  chisel  or  the  Gigli  wire  saw.     (Compare  p.  189.) 

Pseudarthrosis  requires  osteotomy  much  more  fre- 
quently, especially  in  children,  in  whom  the  fractured 
ends  have  a  tendency  to  become  thin  and  atrophic, 
thus  reducing  the  extent  of  their  surface,  which  is  a 
most  unfavorable  item  in  the  question  of  agglutination. 
Such  patients  are  unable  to  work  without  an  immo- 
bilizing apparatus  or  a  prosthesis.  Wherever  the  sur- 
faces are  too  small  for  perfect  approximation,  the 
bone-fragments  should  be  freshened  laterally  and 
united  by  strong  silver  wire.     (See  Fig.  13  c.) 

It  is  of  the  greatest  importance  that  no  periosteum 
should  be  sacrificed  during  the  operation. 

In  the  event  of  extensive  loss  of  substance  of  the 
tibia,  the  upper  tibial  fragment  may  be  united  with  the 
lower  portion  of  the  fibula  after  the  latter  has  been 
trimmed  proportionally. 


FOOT. 

Fracture  of  the  foot  concerns  either  the  tarsal  or 
the  metatarsal  bones  or  the  phalanges. 

Fractures  of  the  tarsal  bones  are  always  caused 
by  direct  violence  (passing  of  a  carriage-wheel  (Fig. 
144),  falling  of  a  heavy  weight  upon  the  tarsus). 
There  is  often  extensive  destruction  of  the  soft  tissues 
present  at  the  same  time.  The  astragalus  and  calca- 
neum  are  the  tarsal  bones  most  frequently  involved  in 
these  fractures. 

Fracture  of  the  astragalus  (Fig.  145)  is  generally 
caused  by  a  fall,  its  neck  representing  the  seat  of  pre- 


PELVIS    AND    LOWER    EXTREMITY 


227 


Fig.  144. — Fracture  of  tarsal  bones,  caused  by  a  heavy  truck,  followed  by 
gangrene  of  foot,  in  a  boy  four  years  of  age.  Line  of  demarcation  above  the 
malleoli  ecchvmotic,  but  healthy  integument  appearing  prominent  above  the  gan- 
grenous area;   skin  peeling  off  from  the  gangrenous  dorsum,  (ten  days  after  the 

injury) . 


Fig.  145. — Compression  fracture  of  astragalus  in  a  twenty-eight-year  old  laborer 
who  was  run  over  (four  weeks  after  the  injury). 


22; 


FRACTURES    OF    SPECIAL    REGIONS. 


dilection.  It  is  often  associated  with  other  severe 
injuries  of  the  ankle-joint.  The  atragalus  is  a  peculiar 
bone  inasmuch  as  it  articulates  with  four  different  bones 
and  shows  no  point  of  insertion  for  any  tendon.  Its 
fracture  may  concern  the  body  as  well  as  the  neck  of 
the  capitulum. 

The  signs  consist  in  the  presence  of  local  pain  and 
tenderness,  crepitus,  and  loss  of  function.  In  the  rare 
event  of  displacement  the  possibility  of  dislocation  may 
be    thought   of.     The    considerations  would    be    then 


Fig.  146. — Fracture  of  the  calcaneum. 


that  the  malleoli  appear  to  be  intact,  that  there  is 
considerable  shortening  of  the  extremity,  and  that  the 
characteristic  contours  of  the  astragalus  can  be  well 
palpated.  Fracture  of  the  astragalus  often  remains 
unrecognized  and  is  treated  for  malleolar  fracture  or 
distortion  of  the  ankle-joint.  The  Rontgen  rays,  of 
course,  will  always  disclose  the  true  condition. 

The  treatment  consists  in  reposition  in  case  of  dis- 
placement, and  this  is  possible  sometimes  only  after 
division   of  the  tendo  Achillis.     If  there   be  but  little 


PELVIS    AND     LOWER    EXTREMITY 


229 


swelling,  immobilization  is  accomplished  by  a  plaster- 
of-Paris  dressing.  Otherwise,  especially  in  the  event 
of  synovitis,  wire  splints  in  connection  with  the  appli- 
cation of  Burow's  solution  are  indicated.     (See  p.  67.) 


Fig.  147. — Non-reduced  fracture  of  the  calcaneum,  showing  considerable 
sideward  displacement,  thus  resembling  dislocation,  in  a  man  thirty-eight  years  of 
age.      Enormous  swelling  (two  weeks  after  the  injury). 

Fracture  of  the  calcaneum  (Fig.  146)  is  caused  either 
by  direct  violence  (fall  from  a  high  point,  passing  of  a 
cart- or  carriage-wheel)  or  by  indirect  violence  (sudden 
contraction  of  the  tendo  Achillis).     It  predominates  in 


230 


FRACTURES    OF    SPECIAL    REGIONS. 


masons,  roofers,  miners,  and  workmen  on  elevated 
railroads.  It  concerns  either  the  body  or  the  processes 
of  the  bone. 

The  signs  consist  in  ecchymosis,  local  pain,  displace- 
ment, crepitus,  and  loss  of  function.  The  arch  of  the 
foot  sinks  down  and  the  foot  appears  flat.  Some- 
times the  swelling  following  the  injury  is  so  consider- 


Fig.  148. — Oblique  fracture  of  first  metatarsus  in  a  rachitic  girl  of  twelve  years 
healed  without  deformity  (five  weeks  after  the  injury). 


able  as  to  prevent  exact  palpation  ;  and  as  a  conse- 
quence distortion  or  malleolar  fracture  may  be  errone- 
ously supposed  to  exist. 

The  prognosis  as  to  function  is  always  doubtful. 

The  treatment  consists  in  reposition  and  immobiliza- 
tion.    The    first   requirement   sometimes    can   not   be 


PELVIS    AND    LOWER    EXTREMITY.  23 1 

fulfilled,  apposition  of  the  fragments  being  possible 
only  by  bone  suture  or  ivory  pegs.  Ordinarily,  the 
displacement  can  be  overcome  by  resting  the  leg 
upon  a  double  inclined  plane.  In  case  of  excessive 
callus  formation  resection  of  the  exuberant  masses 
is  indicated.  If  either  the  calcaneum  or  astragalus 
is  crushed,  amputation  should  be  performed  without 
delay. 

Fractures  of  the  scaphoid,  cuneiform,  and  cuboid  bones 
fall  under  the  same  considerations  as  those  of  the 
metatarsal  bones.  In  all  these  fractures  the  arch  of 
the  foot  sinks  down,  causing  talipes-position. 

Fractures  of  the  metatarsal  bones  (Fig.  148)  and 
the  phalanges  are  always  produced  by  direct  violence 
(falling  of  a  heavy  weight,  passing  of  a  wagon-wheel, 
the  latter  being  an  especially  frequent  cause  in  chil- 
dren). Such  fractures  are  either  isolated  or  simultane- 
ous, sometimes  all  the  bones  being  fractured  at  the 
same  time.  Usually  these  injuries  are  associated  with 
lesions  of  the  soft  tissues.  Their  superficial  location 
makes  recognition  of  the  character  of  these  injuries 
easy,  as  a  rule. 

Fracture  of  a  metatarsal  bone,  especially  the  second 
or  third,  is  frequently  observed  in  the  army,  as  a  con- 
sequence of  overburdening  the  marching  soldier.  In 
the  pre-R6ntgenian  era  this  much  dreaded  condition, 
known  as  "foot  edema,"  was  regarded  as  dependent 
upon  a  pathologic  change  in  the  soft  tissues. 

The  treatment  consists  in  immobilization  by  a  small 
plaster-of-Paris  dressing  after  reposition  is  done. 
Union  generally  becomes  perfect  in  three  weeks. 

In  compound  fractures  the  wire  splint  should  be 
used  in  connection  with  antiseptic  lotions.    (See  p.  67.) 


232  FRACTURES    OF    SPECIAL    REGIONS. 

Later  on,  the  fenestrated  plaster-of-Paris  dressing  is 
to  be  employed.      (Fig.  5.) 

If  the  bones  are  crushed,  amputation  should  not  be 
delayed. 

FRACTURES  OF  THE  BONES  OF  THE 
TRUNK. 

Fractures  of  the  bones  of  the  trunk  are  divided  into 
those  of  the  thoracic  wall  (ribs  and  sternum)  and  those 
of  the  spinal  column  (body,  arch,  and  the  spinous  and 
transverse  processes). 

FRACTURE  OF  THE  RIB. 

Fractures  of  the  ribs  (Fig.  149),  while  rare  in  chil- 
dren, are  frequent  in  adults,  and  represent  fifteen  per 
cent,  of  all  fractures.  The  injury  may  be  caused  by 
direct  as  well  as  by  indirect  violence.  In  the  first 
event  (blow  against  the  thoracic  wall,  fall  at  the  margin 
of  the  sidewalk,  staircase,  table,  etc.)  the  fragments 
are  generally  driven  inward.  (Fig.  150.)  If  caused 
by  a  gunshot,  the  rib  is  splintered,  the  intrathoracic 
organs  being  generally  also  involved.  A  simple 
transverse  fracture  may  be  produced  by  a  bullet  fired 
from  so  great  a  distance  that  its  force  is  considerably 
diminished  when  it  strikes  the  rib. 

If  the  fracture  is  caused  by  indirect  violence  (as, 
for  instance,  by  compression  of  the  thorax),  it  is  often 
associated  with  fracture  or  contusion  of  the  humerus. 
In  rare  instances  the  fracture  is  produced  by  muscular 
contraction,  in  which  event  the  fragments  are  generally 
driven  outward. 

According  to  the  age  of  the  patient  or  to  the  degree 
of  violence,  an  infraction  (Fig.  149)  or  a  true  fracture 


(Fig.  150)  may  result.  Infractions  are  much  more 
frequent  than  fractures.  In  children  the  thorax  is  so 
elastic  that  fracture  is  caused  only  by  a  considerable 
decree  Gf  violence. 

The  signs  consist  in  intense  local  pain  and  in  the 
crepitus  that  results  if  the  fragment  is  pressed  down- 
ward by  the  palm  of  the  hand.  Manual  pressure  also 
increases  the  painful  sensation  during  the  act  of  in- 
spiration. Deep  inspiration  and  stooping  toward  the 
opposite  side  invariably  cause  great  pain.     If  the  rib 


Fig.  149. — Infraction  of  ribs  (no  displacement). 

is  fractured  only,  displacement  generally  does  not  take 
place,  but  if  several  ribs  are  broken,  as  shown  by 
figure  150,  considerable  displacement  may  result.  It 
is  in  these  cases  that  the  intercostal  artery  may  become 
injured,  so  that  an  aneurysm  may  develop.  Fractures 
in  the  vicinity  of  the  vertebrae  impair  the  function  of 
the  articulatio  costotransversalis  and  costovertebralis. 
In  case  the  lungs  are  injured,  hemoptysis  is  always, 
and  hemothorax,  pneumothorax,  and  emphysema  are 
sometimes,   present.     The   last-named   condition   may 


234 


FRACTURES    OF    SPECIAL    REGIONS. 


extend  to  the  neck  and  abdomen,  and  in  severe  cases 
it  may  involve  the  whole  body,  the  air  escaping  from 
the  lung'  into  the  surrounding  connective  tissue.  The 
left  fourth,  fifth,  and  sixth  ribs  at  their  sternal  junctions 
endanger  the  pericardium  and  vagus,  while  the  ante- 
rior splinter-fractures  of  the  sixth   rib  may  injure  the 


Fig.  150. — Fracture  of  ribs  about  their  angles,  causing  kyphosis,  in  a  woman 
of  fifty  years.  On  the  left,  the  fourth  rib  shows  slight,  the  fifth  considerable,  dis- 
placement. On  the  right,  the  fragments  of  the  fifth  rib  overlap,  while  the  sixth 
rib  sh6\vs  moderate  displacement. 


pleural  sinus.       The  right  seventh,  eighth,  and   ninth 
ribs  may  cause  laceration  of  the  liver  tissue. 

The  treatment  should  be  mainly  directed  to  immo- 
bilization. Taking  into  account  the  relation  of  the  ribs 
to   the   pleura  and  lung,   it   is   evident  that  immobili- 


FRACTURES    OF    THE    BONES    OF    THE    TRUNK.         235 

zation  should  not  be  expended  upon  the  thoracic  wall 
alone,  but  must  also  affect  the  intrathoracic  organs. 

The  first  requisite  will  be  attained  by  the  fixation 
of  the  fragments,  which  is  accomplished  by  a  large 
and  broad  strip  of  rubber  adhesive  plaster  or  a  large 
piece  of  moss-board  (see  Fig.  23)  applied  during  ex- 
piration. The  second  and  more  important  requisite, 
immobilization  of  the  lungs, — in  other  words,  reduc- 
tion and  diminution  of  the  respiratory  movements, — 
is  fulfilled  by  a  liberal  administration  of  opiates. 

Pleuritis  sicca,  one  of  the  most  frequent  results  of 
simple  infraction  as  well  as  of  true  fracture  of  a  rib, 
is  treated  after  general  principles  (rest  in  bed,  fomen- 
tations, opiates,  etc.). 

The  same  views  apply  in  the  much  rarer  event  of 
pneumonia,  which,  as  a  rule,  is  of  moderate  extent 
and  significance.  Sometimes  tuberculosis  develops 
after  an  injury  of  the  pleura  or  the  lungs. 

Hemothorax  or  pneumothorax,  if  present  to  a  mod- 
erate extent,  demands  aspiration,  under  the  most 
thorough  aseptic  precautions.  (Compare  p.  198.)  In 
most  cases,  however,  it  is  more  rational  to  expose  the 
pleural  sac  by  the  resection  of  three  or  more  ribs.  The 
same  holds  good  in  pyothorax.  As  to  the  technic, 
compare  author's  description.* 

Pericarditis  is  not  infrequently  observed  after  rib- 
fracture.  If  a  splinter-fragment  has  pierced  the  peri- 
cardium, injury  to  the  heart  may  also  result.  The  true 
character  of  the  trauma  can  always  be  elicited  by  the 
Rontgen  rays.  If,  for  instance,  the  clinical  symptoms 
are  slight,  and  the  rays  show  no  displaced  splinters 
in  the  direction  of  the  pericardium,  medical  treatment 

***  International  Med.  Magazine,"  January,  1897. 


236 


FRACTURES    OF    SPECIAL    REGIONS. 


alone  is  in  order.  Even  if  a  bullet,  after  having  frac- 
tured a  rib,  has  entered  the  pericardium,  there  may  be 
no  need  of  surgical  interference,  no  severe  symptoms 
being  present.  An  autopsy  made  by  the  author  on 
a  patient  who  was  shot  through  the  thorax  eight  years 


Fig.  151. — Compound  fracture,  showing  displacement  of  fifth,  sixth,  and  seventh 
ribs,  in  a  boy  ten  years  of  age  (four  weeks  after  the  injury). 

before  his  death  revealed  a  bullet  embedded  in  fibrous 
tissue  in  the  pericardial  sac,  where  it  had  never  caused 
any  disturbance. 

But  the  evidence  of  a  sharp  bone-splinter  pointing 
toward  the  pericardium  indicates  the  urgent  necessity 
of  exposing  the  pericardial  sac  after  the  resection  of 


FRACTURES  OF  THE  BONES  OF  THE  TRUNK.    237 

the  left  fourth,  fifth,  and  sixth  ribs.  They  do  not 
necessarily  need  to  be  resected  in  their  totality,  but 
may  be  folded  up  at  their  sternal  junctions  like  a 
bone-flap  of  the  skull.     (Fig.  158.) 

It  goes  without  saying  that  in  such  cases  the  clinical 
symptoms  are  severe  according  to  the  anatomic  con- 
dition. 

The  signs  of  an  injury  to  the  heart  are  severe  shock 
(fainting,  cyanosis,  weak  pulse),  pulsation  in  the 
wound,  hemopericardium,  and  the  murmur.  If  the 
fourth  and  fifth  ribs  are  dissected  at  the  mammillary 
line  and  folded  up  at  the  sternum,  the  anterior  surface 
of  the  right  and  a  portion  of  the  left  ventricle  are 
exposed.  The  pericardium  must  be  severed  from  the 
pleura.  Any  wound  in  the  heart  must  be  united  with 
silk  (medium  size).  The  left  ventricle  is  best  sewed 
during  systole,  and  the  right  during  diastole. 

In  compound  fractures  of  a  rib  (Fig.  151)  the  pack- 
ing of  the  wound  with  iodoform  gauze  is  indicated.  If 
there  be  much  hemorrhage,  the  packing  must  be  done 
tightly  and  extensively,  in  the  form  of  a  tampon  bag.* 
If  the  extent  of  emphysema  is  moderate,  no  inter- 
ference is  required  ;  but  if  it  be  extensive,  multiple 
incisions  are  indicated. 

To  sum  up,  it  can  readily  be  seen  that  the  prog- 
nosis of  fracture  of  the  ribs  depends  entirely  upon 
the  degree  of  participation  of  the  intrathoracic  organs. 
In  simple  cases  union  is  perfected  in  from  three  to 
four  weeks. 

Fractures  of  the  costal  cartilages  occur  gener- 
ally at  their  junction  with  the  ribs,  sometimes  also  in 

*  Compare  author's  "  Manual  on  Surgical  Asepsis,"  W.  B.  Saunders, 
Phila.,  p.  209. 


233 


FRACTURES    OF    SPECIAL    REGIONS. 


their  continuity.  The  consideration  of  the  etiology, 
signs,  and  treatment  of  this  condition  is  identical  with 
that  of  fracture  of  the  ribs.  It  must  be  considered 
that  in  aged  people  the  cartilages  become  ossified. 

FRACTURE  OF  THE  STERNUM. 

Fracture  of  the  sternum  (Fig.  152)  is  rare  (less  than 
one  per  cent,  of  all  fractures).     It  is  generally  caused 


Fig.  152. — Fracture  of  the  sternui 


by  direct  violence  (heavy  weight  falling  upon  the 
chest,  gunshot  wound,  etc.).  The  line  of  fracture  is 
nearly  always  transverse.  It  is  but  exceptional  that  it 
is  caused  by  indirect  violence  (muscular  contraction, 
sudden  bending  of  the  trunk,  the  chin  being  pressed 
against  the  sternum). 

If  caused  by  a  gunshot  wound,  the  seat  of  the  frac- 


FRACTURES    OF    THE    BONES    OF    THE    TRUNK.         239 

ture  may  be  at  any  portion  of  the  sternum.  Other- 
wise it  is  generally  at  the  junction  of  the  manubrium 
with  the  corpus. 

The  signs  are  local  circumscribed  pain,  more  or 
less  displacement  and  crepitus,  cough,  and  sometimes 
hemoptysis  and  dyspnea. 

The  prognosis  is  favorable  except  in  cases  in  which 
there  is  injury  done  to  the  mediastinum. 

The  treatment  consists  in  reposition  of  the  frag- 
ments. This  is  accomplished  by  putting  the  patient 
into  a  reclined  position  by  placing  a  large  pillow  under 
him,  so  that  the  receding  fragment  protrudes.  The 
head  should  be  bent  far  backward  at  the  same  time. 
If  this  procedure  does  not  prove  to  be  efficient,  ex- 
tension with  Glisson's  cradle  is  advisable. 


FRACTURE  OF    THE    SPINAL    COLUMN. 

Fractures  of  the  spinal  column  (Figs.  153,  154)  are 
rare  (less  than  one  per  cent.),  and  are  subdivided  into 
fractures  of  the  vertebral  body,  the  arch,  and  the 
spinous  and  transverse  processes. 

Fracture  of  the  vertebral  bodies  occurs  gener- 
ally in  the  dorsal  and  lumbar  portions.  The  place  of 
predilection  is  between  the  twelfth  dorsal  and  the  first 
lumbar,  and  at  the  fifth  or  sixth  cervical  vertebra.  It 
is  generally  caused  by  indirect  violence  (heavy  weight 
falling  upon  head  or  shoulder,  fall  from  horse  or 
bicycle).  Direct  violence  produces  it  but  exception- 
ally. 

The  direction  of  the  fracture-line  may  be  either 
oblique,  transverse,  or  longitudinal.  The  first  variety 
is  the  most  frequent,  the  last-named  the  rarest. 


240 


FRACTURES    OF    SPECIAL    REGIONS. 


Infractions  or  fissures  are  also  observed,  but  they 
are  seldom  diagnosticated  on  the  living  patient. 
Sometimes  more  than  one  vertebra  is  concerned. 

The  most  important  sign  is  the  traumatic  kyphosis, 
produced  by  displacement  of  the  spinous  processes, 
whereby  a  prominence  is  caused.  Naturally,  there  is 
always  circumscribed  pain.  Crepitus  and  abnormal 
mobility  are  generally  absent. 

In  case  of  a  crushing  of  the   bone  the  spinal  cord 


Fig.  153- — Position  of  trunk  in  fracture  of  the  spinal  column. 


hardly  ever  escapes  injury,  the  latter  generally  being 
of  the  nature  of  a  severe  contusion.  Lighter  injuries, 
such  as  commotion  or  compression,  are  of  exceptional 
occurrence. 

In  the  event  of  medullary  contusion  there  are  well- 
marked  signs  of  motor  and  sensory  disturbance:  viz., 
paralysis  of  both  legs,  of  rectum  and  bladder,  local 
anesthesia  of  the  anal  and  perineal  regions,  and  some- 
times   priapism.     In    severe   cases  dyspnea  and  high 


FRACTURES  OF  THE  BONES  OF  THE  TRUNK.    24 1 

temperature  may  complete  the  symptom-group  of  this 
grave  condition. 

While  in  commotion  and  compression  (caused  in 
some  instances  by  a  blood  extravasation)  there  is  only 
slight  paresis,  which  disappears  in  a  few  days,  in  con- 
tusion the  paralytic  symptoms  remain  unchanged. 
Spinal  myelitis  develops,  with  an  ascending  tendency, 
the  paralysis  progressing  in  the  centripetal  direction. 

The  paretic  bladder  breeds  cystitis  and  pyeloneph- 
ritis, and  the  anesthesia  of  the  paralyzed  portions  tends 
to  decubitus  on  the  prominent  bone-portions  of  the 
pelvis  and  the  lower  extremities,  so  that  there  are 
present  all  the  conditions  for  the  development  of 
pyemia. 

The  higher  up  the  fracture  takes  place,  the  less  favor- 
able is  the  prognosis.  Importance  should  be  attached 
also  to  the  proximity  of  the  injury  to  the  vital  organs. 

If  in  fracture  of  the  first  and  second  cervical  verte- 
brae the  spine  is  compressed  on  account  of  much  dis- 
placement, death  is  almost  instantaneous.  If  the  de- 
gree of  displacement  is  very  slight,  the  patient  may 
live  for  a  short  while. 

In  view  of  the  fact  that  the  brachial  plexus  is  com- 
posed of  the  fifth,  sixth,  seventh,  and  eighth  cervical 
nerves,  as  well  as  of  the  first  dorsal  nerve,  it  will  be 
understood  why  paralysis  of  the  upper  extremities  as 
well  as  of  the  abdominal  and  intercostal  muscles  is 
present  in  fracture  above  the  third  dorsal  vertebra  ; 
also  why  the  character  of  the  respiration  is  distinctly 
diaphragmatic,  and  why  it  is  the  diaphragm  only,  be- 
sides a  few  cervical  muscles,  that  keeps  up  the  respi- 
ratory function. 

If  the   phrenic   nerve,   which   branches  off  between 
16 


242 


FRACTURES    OF    SPECIAL    REGIONS. 


the  third  and  fourth  cervical  vertebrae,  is  compressed 
in  this  region,  its  paralysis  will  be  the  consequence,  and 
death  will  follow  almost  instantly. 


Fig.  154. — Fracture  of  dorsal  vertebra,  causing  displacement  and  contusion. 


In  fracture  between  the  third  dorsal  and  the  third 
lumbar    vertebra     the     spine     is    injured     below    the 


FRACTURES  OF  THE  BONES  OF  THE  TRUNK.    243 

brachial  plexus.  Consequently,  the  function  of  the 
arm  remains  intact,  while  the  functions  of  the  bladder, 
the  rectum,  and  the  lower  extremity  are  suspended, 
first  retention,  and  later  on  incontinence,  of  urine  and 
feces  setting  in. 

If  the  line  of  fracture  is  situated  higher  up,  the 
abdominal  muscles  may  also  become  paralyzed.  Then 
tympanites  will  be  produced,  which  pushes  the  dia- 
phragm upward  so  that  respiration  is  greatly  inter- 
fered with.  Some  of  the  intercostal  muscles  may  also 
be  paralyzed,  so  that  the  respiratory  difficulty  is  so 
much  more  increased. 

There  may  also  be  the  chain  of  symptoms  of  irrita- 
tion, such  as  hyperesthesia,  neuralgia,  and  spasms. 
The  reflexes  are  increased  if  the  compression  is  con- 
siderable, while  they  may  be  unaltered  if  it  is  slight. 
The  vasomotor  sphere  may  react  by  an  enormous 
elevation  of  temperature  if  the  lower  cervical  region  is 
involved.  Continuous  erection  and  frequent  ejacula- 
tions of  sperma  may  also  persist  for  days. 

The  treatment  consists  in  reposition  of  the  fragments. 
Sometimes  this  can  be  accomplished  by  manual  force 
applied  after  the  induction  of  profound  anesthesia. 
This  can  especially  be  done  in  the  lower  dorsal  and 
in  the  lumbar  portions.  The  fragments  are  drawn 
apart  by  placing  the  patient  in  Glisson's  cradle, 
counterextension  being  accomplished  by  elevating  the 
bed.  Later  on,  a  plaster-of-Paris  corset  is  applied 
while  forcible  weight-extension  is  kept  up. 

If  reposition  is  impracticable,  distraction  or  the 
forcible  separation  of  the  fragments  must  be  re- 
sorted to. 

In  the  treatment  great  stress  has  to  be  laid  on  very 


244  FRACTURES    OF    SPECIAL    REGIONS. 

careful  control  and  nursing.  Frequent  change  of  posi- 
tion, while  necessary,  must  be  done  under  great  pre- 
cautions, as  it  must  be  remembered  that  even  a  light 
torsion  of  the  injured  spine  may  cause  instant  death. 
The  patient  rests  best  on  a  water-pillow  or,  preferably, 
on  a  water-bed. 

Decubitus  must  be  prevented  by  exercising  the 
most  minute  cleanliness  and  by  placing  the  patient 
upon  rubber  water-bags.  Frequent  change  of  position 
is  also  required. 

Decomposition  of  the  urine  must  be  counteracted 
by  frequent  catheterization,  followed  by  irrigation  with 
a  weak  solution  of  bichlorid  of  mercury  (i  :  25,000) 
and  injection  of  a  five  per  cent,  emulsion  of  iodoform 
in  glycerin. 

With  the  aid  of  the  Rontgen  rays  the  type  of  the 
fracture  and  the  size  and  number  of  the  splinters  and 
their  location  can  be  so  well  represented  that  the 
indications  for  the  mode  of  treatment  are  set  forth 
clearly.  If  there  is  only  slight  angular  displacement, 
reduction  can  nearly  always  be  accomplished.  But  in 
the  event  of  intraspinal  hemorrhage  and  when  bone- 
fragments,  driven  into  the  canal,  press  upon  the  cord, 
operative  interference  is  required. 

Under  the  application  of  the  Rontgen  rays  the  re- 
sults of  operation,  which  formerly  had  been  confined 
to  exploration,  became  much  more  encouraging.  The 
field  of  operation  being  outlined  by  the  skiagraph, 
the  modus  operandi  could  be  determined  before 
operation.  While  at  one  time  it  was  deemed  advis- 
able to  expose  a  large  portion  of  the  spinal  column  in 
order  to  ascertain  that  every  possible  injury  had  really 
been   reached,  now  all  the  operative   procedures  can 


FRACTURES  OF  THE  BONES  OF  THE  TRUNK.    245 

be  carried  out  under  the  indication  of  the  rays  with 
ease  and  security,  even  the  length  of  the  incision 
necessary  for  the  removal  of  bone-splinters  being 
shown  by  the  skiagraph. 

It  is  surprising  that  surgeons  who  find  it  most  nat- 
ural to  relieve  by  immediate  operation  bone-pressure 
caused  by  a  depressed  fracture  of  the  skull  should 
hesitate  to  perform  the  similar  operations  upon  the 
spinal  column.  Nothing,  indeed,  is  more  natural  than 
reduction  or  removal  of  a  fragment  pressing  upon  the 
spinal  cord.  Blood-clots  can  then  be  evacuated  from 
the  cord  ;  and  its  membranes,  and  even  wounds  of  the 
nerve-tissue,  may  be  united.  It  is  hardly  necessary  to 
add  that  such  procedures  must  be  carried  out  under 
the  most  stringent  aseptic  precautions.     (Compare  p. 

52.) 

The  best  method  of  exposing  the  spinal  canal  (tre- 
phining of  the  spinal  canal,  or  laminectomy)  is  by  the 
formation  of  a  lateral  flap.  This  is  done  by  making 
an  incision  about  seven  inches  long  over  the  arches 
down  to  the  periosteum  and  by  reflecting  the  soft  tis- 
sues to  the  bases  of  the  spinous  processes,  which  are 
then  divided  with  cutting  bone-forceps.  The  processes 
may  be  lifted  up  in  the  flap,  like  a  bone-flap  in  the 
skull.  (Fig.  160.)  The  dissection  is  continued  to  the 
other  side  until  the  exposure  of  the  fractured  area  is 
complete.  Now  the  depressed  bone  may  be  lifted  or 
removed,  a  hematoma  may  be  evacuated,  and  lacer- 
ated nerves  may  be  united.  If  the  bone-flap  is  rein- 
serted now,  union  by  first  intention  can  be  expected, 
the  remaining  bone-gap  being  filled  up  with  thick 
fibrous  tissue. 


246  FRACTURES    OF    SPECIAL    REGIONS. 

But  if  suppuration  is  present,  the  principles  of 
open  wound  treatment  should  be  kept  up.* 

In  case  of  excessive  callus,  pressing  upon  the  cord, 
or  of  faulty  union,  laminectomy  is  also  indicated,  even 
at  a  late  period.  Sometimes  in  such  cases  occlusion 
of  the  spinal  canal,  caused  by  adhesions  of  the  mem- 
branes, is  observed.  It  goes  without  saying  that  they 
must  be  thoroughly  freed. 

In  view  of  the  soft,  spongy  consistence  of  the  verte- 
bral bodies,  it  is  evident  that  long-continued  immo- 
bilization— at  least  three  months — is  necessary  for 
thorough  consolidation.  If  the  patient  is  allowed  to 
get  up  too  early,  compression  will  be  increased  by  the 
weight  of  the  body,  and  kyphosis  will  be  a  natural 
consequence. 

In  severe  cases  the  treatment  may  be  continued  for 
a  whole  year.  Massage  treatment  should  be  com- 
menced after  three  months  ;  later  on,  faradization  is  in 
order. 

Fractures  of  the  arch  are  rare,  and  occur  more 
frequently  in  the  lower  than  in  the  upper  portion  of 
the  vertebral  column.  They  are  caused  by  indirect 
violence  (fall  or  blow  on  the  long  spinous  process) 
the  effect  of  which  is  transferred  to  the  arch. 

Among  the  signs  the  predominant  one  is  the  down- 
ward displacement  of  the  spinous  process  of  the  ver- 
tebra involved.  Otherwise  the  signs  as  well  as  the 
treatment  of  this  type  require  much  the  same  consid- 
eration as  those  of  the  fracture  of  the  vertebral  body. 

Fracture  of  the  spinous  and  transverse  pro- 
cesses is  extremely  rare. 

*  Compare  author's  essay  on  "Laminectomy,"  "  American  Medico- 
Surgical  Bulletin,"  Feb.  i,  1894. 


FRACTURES  OF  THE  SKULL.  247 

Fractures  of  the  spinous  processes  are  caused  by 
direct  violence  (blow  or  fall),  and  prevail  at  the  lower 
dorsal  and  the  lumbar  portions  of  the  vertebral 
column. 

The  signs  are  well  marked,  the  predominant  one 
being  abnormal  mobility  of  the  fragment. 

Fractures  of  the  transverse  processes  are  still  rarer, 
and  their  recognition  is  extremely  difficult  on  account 
of  the  thick  muscular  layer  protecting  them. 

The  treatment  of  this  fracture  type  is  very  simple. 
Patients  should  assume  the  dorsal  decubitus  for  two 
weeks,  and  are  then  provided  with  a  plaster-of-Paris 
corset  for  another  few  weeks. 

A  good  skiagraph  will  show  a  fissure  as  well  as  an 
infraction  at  any  part  of  the  spinal  column.  In  repro- 
ducing it  in  print,  however,  much  of  the  delicacy  of  the 
representation  becomes  lost,  and  for  that  reason  the 
author  has  preferred  not  to  offer  any  of  his  skiagraphic 
illustrations  of  this  fracture  type. 

FRACTURES    OF   THE    SKULL. 

Fractures  of  the  skull  are  comparatively  rare  (1.3 
per  cent,  of  all  fractures).  They  deserve  special  con- 
sideration for  the  reason  that  their  course  can  seldom 
be  foretold  with  certainty,  extensive  penetrating  inju- 
ries sometimes  healing  with  little  reaction  and  no  ill 
consequence,  while  comparatively  small  lesions  of  ap- 
parent insignificance  are  liable  to  be  followed  by  fatal 
meningitis.  They  concern  the  vertex  or  the  base  of 
the  skull  or  the  bones  of  the  face. 

Fractures  of  the  skull  are  uncommon  in  children  on 
account  of  the  thin  and  elastic  structure  of  the  bones, 


248         FRACTURES  OF  SPECIAL  REGIONS. 

which  makes  them  yield  to  direct  violence.  This  ex- 
plains why  fissures  and  fractures  of  the  tabula  vitrea 
are  so  extremely  uncommon  in  childhood.  The  bones 
being  united  by  soft  sutures  and  the  dura  mater  being 
firmly  adherent  to  the  infantile  cranium,  it  follows  that 
an  injury  of  the  skull  will  be,  with  few  exceptions, 
combined  with  a  laceration  of  the  intracranial  tissues  ; 
at  least,  of  the  dura  mater.  Sometimes  the  arteria 
meningea  media  is  found  ruptured.  Such  cases  re- 
quire very  careful  observation  and  judgment,  since  the 
early  symptoms  of  meningitis  or  encephalitis  may  be 
veiled. 

The  treatment  consists  mainly  in  rigid  asepsis.  In 
hernia  cerebri  caused  by  compound  fracture  of  the 
skull  transplantation  of  bone-tissue  is  indicated.  In 
fracture  of  the  skull  in  older  children,  in  whom  the 
bones  are  consolidated,  the  conditions  are  the  same  as 
in  adults. 

FRACTURES  OF  THE  VERTEX 

represent  the  great  majority  of  fractures  of  the  skull, 
and  are  nearly  always  caused  by  direct  violence  (fall 
or  blow  on  the  head,  weapon,  gunshot).  Indirect 
violence,  the  force  inflicted  radiating,  causes  it  but 
rarely.  (An  illustration  of  the  insignificance  of  indi- 
rect violence  is  afforded  by  the  case  of  President  Lin- 
coln, in  which  the  bullet,  after  having  pierced  the  left 
side  of  the  occiput,  went  to  the  cranial  base  below  the 
right  anterior  lobe.  The  autopsy  revealed  a  fracture 
in  the  roof  of  the  right  orbit,  which  had  not  been 
touched  by  the  bullet.) 

There  may  be  a  simple  fissure  in  the  skull,  as  well  as 
comminuted  and  compound  fractures. 


FRACTURES    OF     THE    SKULL. 


249 


A  remarkable  feature  of  fractures  of  the  vertex  is 
the  much  greater  extent  of  the  fracture  in  the  internal 


Fig-  155- — Schematic  representation  of  dissemination  of  force. 


F'g-  156. — Protrusion  at  the  inner  table,  caused  by  a  blow  from  a  hammer. 

table  than  in  the  external.     This  is  caused  by  the  force 
bending  the  portion  involved  inward.     Thus  the  outer 


250 


FRACTURES    OF    SPECIAL    REGIONS. 


convexity  and  the  concavity  of  the  inner  surface  are 
replaced  by  a  flatness  of  that  portion,  the  external 
table  being  compressed  and  the  internal  table  being 
overstretched.  (Fig.  155.)  The  extent  of  the  frac- 
ture naturally  is  greater  in  the  inner  table.  When 
a  stick  is  broken,  the  separation  of  the  fragments 
commences   at   the   overstretched    side,  or   convexity, 


Fig.  157. — Fracture  by  gunshot,  comminuted  type. 

not  on  the  compressed  concavity.  In  like  manner  the 
greatest  extent  of  fracture  in  injuries  of  the  vertex 
is  shown  upon  the  concave  side. 

There  are  isolated  fractures  of  the  external  table  as 
well  as  of  the  internal.  The  latter  injury  occurs  some- 
times when  a  force,  applied  from  without,  is  too  weak 
to  compress  the  external  table  to  such  an  extent  as  to 


FRACTURES    OF     THE    SKULL. 


251 


cause  its  fracture,  but  still  is  powerful  enough  to 
stretch  the  molecules  of  the  inner  table  to  such  an  ex- 
tent that  a  fracture  must  result.  (Fig.  156.)  On  the 
other  hand,  it  may  happen  that  a  force  (gunshot)  in- 
flicted from  within  is  strong  enough  to  fracture  the 
inner,  but  too  weak  to  permit  of  its  fracturing  the 
outer,  table. 

Fissures  may  be  limited  to  the  external  table,  and 


Fig.  158. — Fracture  of  the  orbit  caused  by  a  revolver  bullet,  which,  after  having 
perforated  the  left  orbit,  was  arrested  at  the  right  sphenoid  process. 

may  represent  but  a  small  crack  ;  or  they  may  show 
an  irregular  radiating  fracture-line  (stellate),  the 
branches  of  which  separate  widely. 

Fractures  are  generally  of  the  comminuted  char- 
acter, their  fragments  generally  being  separated  from 
each  other  entirely.  They  may  also  show  an  irregular 
radiating  fracture-line  (splintered  stellate  type).     The 


252  FRACTURES    OF    SPECIAL    REGIONS. 

inner  table  is  always  injured  to  a  greater  extent  than 
the  outer  in  such  cases. 

There  is  often  a  considerable  depression  of  the 
splintered  area,  some  of  the  splinters  projecting 
toward  the  interior  of  the  skull.  Necessarily,  the 
brain  must  in  such  cases  be  more  or  less  injured.  If 
caused  by  gunshot  (Figs.  157  and  158),  there  may  be 
considerable  loss  of  substance.  Usually  there  is  a 
small  round  defect  at  the  outer  table,  comminution  at 
the  inner  one,  and  penetration  of  the  splinters  into 
the  brain-substance. 

The  signs  are  local  as  well  as  general. 

The  local  signs  are  well  marked  in  open  fractures. 
To  ascertain  their  extent  the  injured  area  must  be 
thoroughly  exposed.  Careful  exploration  is  then  made 
by  dilating  the  wound  well  and  keeping  the  wound 
margins  far  asunder. 

Closed  fractures,  if  comminuted,  are  also  easily  diag- 
nosticated, especially  so  if  there  is  depression  present ; 
but  fissures,  which  naturally  show  no  displacement, 
are  recognized  with  difficulty.  Their  circumscribed 
blood  extravasation  below  the  periosteum  and  galea  is 
easily  confounded  with  a  hematoma  of  the  galea  caused 
by  simple  contusion.  Local  pain  also  represents  an 
unreliable  symptom,  so  that  without  the  aid  of  the 
Rontgen  rays  a  positive  diagnosis  often  can  not  be 
made. 

The  general  signs  are  more  marked  than  the  local. 
The  function  of  the  brain  being  exercised  by  some  par- 
ticular circumscribed  portions,  it  is  evident  that  from 
the  particular  kind  of  functional  disturbance  the  im- 
pairment of  a  certain  area  can  be  guessed. 

The  expression  of  these  functional  disturbances  may 


FRACTURES    OF     THE    SKULL.  253 

be  either  paralytic  or  spasmodic,  or  both.  Destruction 
of  a  certain  brain-portion  means  destruction  of  function 
— that  is,  paralysis  ;  while  slight  injury  might  only 
mean  irritation,  which  would  find  its  clinical  expression 
in  contractions — spasms. 

In  other  words,  if  the  paralysis  extends  over  a  cer- 
tain group  of  muscles  (circumscribed  paralysis  ;  mono- 
plegia), a  certain  local  injury  must  be  suspected.  The 
same  statement  applies  to  a  combination  of  paralysis 
and  spasm,  while  spasms  of  a  certain  group  of  muscles 
alone  (monospasms)  point  to  a  lighter  injury  of  the 
same  focus.  As  in  the  case  of  analogous  fracture  of 
the  spinal  column  (p.  241),  distinction  has  to  be  made 
between  commotion,  compression,  and  conttision  of  the 
brain. 

Cerebral  commotion  consists  in  the  injury  of  any 
small  brain  particles  combined  with  a  slight  degree  of 
blood  extravasation.  It  is  followed  by  nausea  and 
vomiting,  vasomotor  paralysis,  which  finds  its  expres- 
sion in  the  weak  and  slow  pulse  (in  several  cases,  as 
slow  as  forty  a  minute),  pallor  of  the  face,  coldness  of 
the  extremities,  superficial  respiration,  and  in  the 
sudden  loss  of  consciousness.  The  latter  symptom 
may  be  present  for  only  a  few  minutes,  and  would  then 
point  to  a  slight  degree  of  commotion  only  ;  but  in 
severer  cases  unconsciousness  may  last  for  two  or 
three  days.  Then  there  is  also  retention  of  urine,  as 
well  as  involuntary  passage  of  urine  and  feces.  Among 
the  sequels  of  this  condition  diabetes  mellitus  and  dia- 
betes insipidus  are  sometimes  observed — disturbances 
of  tissue-change  which  would  indicate  an  injury  of  the 
fourth  ventricle  (Claude  Bernard). 

The  most  characteristic  symptom  of  cerebral  com- 


2  54  FRACTURES    OF    SPECIAL    REGIONS. 

motion  is  a  sudden  loss  of  consciousness,  the  patient 
collapsing  at  the  very  moment  he  receives  the  injury. 
The  clinical  picture  shows  the  motionless  patient  in  a 
soporose  condition,  the  face  pale  and  showing  no  ex- 
pression, the  staring  eyes  wide  open  and  the  pupils 
not  reacting.  If  the  arm  or  leg  is  lifted  up,  it  falls 
down  again  without  indicating  any  contraction  of  the 
muscles.  No  irritation  of  any  kind  (yelling  at  the 
patient  or  sticking  him  with  a  pin)  will  produce  reac- 
tion. It  is  only  the  weak,  superficial,  and  slow  res- 
piration, and  the  small,  slow,  and  irregular  pulse  which 
indicate  that  life  is  not  yet  extinct. 

In  a  very  slight  degree  of  commotion,  such  as  is 
often  observed  in  bicycle  accidents,  there  is  loss  of 
consciousness  for  a  few  minutes  only,  followed  by 
slight  headache  and  vertigo,  ringing  in  the  ears,  and  a 
feeling  of  general  weakness,  which  passes  off  in  a  few 
hours. 

Cerebral  compression  is  always  clue  to  extravasation 
from  the  arteries,  especially  the  meningea  media.  It 
increases  gradually,  and  the  amount  of  intracranial 
blood  may  become  so  abundant  that  an  anemic  condi- 
tion of  the  whole  brain  is  produced.  Such  blood  ex- 
travasation taking  place  gradually,  it  follows  that  the 
symptoms  of  pressure  are  also  manifested  by  degrees. 
At  first  muscular  spasms,  combined  with  paralysis  of 
the  extremities  of  the  opposite  side,  are  observed,  while 
later  on  the  paralysis  becomes  general.  These  symp- 
toms are  then  followed  by  loss  of  consciousness  and 
considerable  slowness  of  pulse.  Contrary  to  commo- 
tion, the  face  appears  red,  the  eyes  shine,  and  the 
pupils  are  contracted.  The  quality  of  the  pulse  is  full, 
but  it  may  be  below  forty  a  minute  at  first  ;  later  on,  it 


FRACTURES    OF     THE    SKULL.  255 

becomes  frequent.  Finally,  there  supervenes  an  ex- 
treme slowness  of  respiration.  Among  the  sequels 
epilepsy,  caused  by  pressure  upon  the  cortex,  may  be 
mentioned.      Insanity  also  develops  sometimes. 

Cerebral  contusion  is  due  to  the  penetration  of  a 
bone-splinter  or  missile  into  the  brain.  If  the  pene- 
trating force  (bullet,  stone)  goes  through  the  skull, 
there  is  generally  considerable  comminution,  which  is 
always  followed  by  marked  focal  symptoms.  Motor 
aphasia,  for  instance,  points  to  injury  of  the  left  frontal 
convolution  of  the  left  hemisphere.  When,  in  a  case 
of  gunshot  wound  in  the  temple,  hemiplegia  is  ob- 
served on  the  other  side,  destruction  of  the  motor  cen- 
ters is  to  be  assumed. 

When  modern  firearms  were  introduced,  it  was 
predicted  that  injuries  in  war  would  be  more  humane 
than  they  had  been.  The  size  of  the  new  bullet  being 
reduced  from  0.7  to  0.3  inch,  its  rate  of  projection 
increased  from  four  to  six  hundred  inches  a  second, 
and  its  penetrating  force  being  made  about  six  times 
greater,  it  was  believed  that  the  thinness  and  the  great 
force  of  the  bullet  would  cause  a  clean,  round,  canal- 
like foramen.  This  was  proved  to  be  an  error  by  the 
experiments  of  the  author  made  in  February,  1896,  at 
Governor's  Island,  N.  Y.  As  soon  as  the  author  had 
a  chance  to  utilize  Rontgen's  discovery,  he  studied  the 
form  and  degree  of  destruction  produced  by  the  new 
army  rifle  (Krag-Jorgensen)  in  the  following  manner  : 
Thanks  to  the  courtesy  of  the  officer  in  charge  at  Gov- 
ernor's Island,  the  author  was  enabled  to  skiagraph 
leg  and  skull  immediately  after  they  were  shot  at  by  a 
soldier  of  the  garrison  at  various  distances.  Contrary 
to  all  theories,  the  bones   as  well   as   the  soft  tissues 


256  FRACTURES    OF    SPECIAL    REGIONS. 

showed  the  most  destructive  effect.      Compare,  for  in 
stance,  figure  136,  which  shows  the  tibia  at  its  lower 
third  transformed  into  a  mass  of  bone-splinters. 

If  a  bullet  enters  the  cranial  cavity,  the  intracranial 
pressure  is  immensely  increased,  an  explosive  effect 
taking  place. 

No  doubt  the  lateral  transmission  of  the  energy  of 
the  bullet,  at  least  in  a  zone  of  350  meters,  produces 
extensive  comminution,  and  while  the  tribute  of  ad- 
miration is  due  to  the  genius  of  the  inventor  of  the 
new  instrument  of  destruction,  humanity  itself  has  no 
reason  for  triumph. 

Paralysis  of  the  hypoglossus  or  facial  nerve  implies 
a  contusion  of  the  correlative  centers  of  Rolando's  sul- 
cus, while  paralysis  of  an  arm  or  a  leg  means  an  injury 
of  the  adjacent  centers  (central  sulcus). 

The  relations  of  the  outer  wound  itself  to  the  sup- 
posed intracranial  injury  have,  of  course,  to  be  taken 
into  close  consideration.  If,  for  instance,  there  is  a 
paralysis  of  the  facial  nerve,  destruction  of  the  center 
of  this  nerve  is  to  be  assumed,  provided  the  situation 
of  the  outer  wound  proves  that  the  nerve  itself  could 
not  have  been  injured.  In  such  a  case  the  functional 
disturbance  must  necessarily  be  clue  to  an  intracranial 
injury. 

There  are,  however,  puzzling  reports  of  cases  in 
which,  in  spite  of  extensive  injury  to  the  brain,  focal 
symptoms  were  absent.  The  author,  for  instance, 
observed  a  case  in  which  a  thin  knife  was  thrust  into 
the  left  upper  eyelid  of  a  man  of  thirty-two  years. 
The  wound  was  closed  in  two  days.  No  reaction 
being  observed,  the  patient  attended  to  his  business 
as  usual.     Six  days  later  nausea  and  vertigo,  followed 


FRACTURES  OF  THE  SKULL.  257 

by  convulsions,  set  in.  When  the  author  saw  the 
patient  on  the  following  clay,  delirium  had  supervened. 
An  immediate  operation  was  advised,  but  before  the 
family  would  consent  to  it,  the  patient  died.  The 
autopsy  revealed  the  presence  of  an  abscess  at  the 
base  of  the  brain,  the  blade  of  the  knife  having  pierced 
the  roof  of  the  orbit.  The  lower  surface  of  the  ante- 
rior lobe  also  was  pierced  by  bone-splinters  and  trans- 
formed into  a  pus-focus. 

In  summing  up,  it  is  evident  that  for  commotion  the 

sudden  loss  of  consciousness  and  the  small  pulse,  for 

compression  the  gradual  loss  of  consciousness  and  the 

full,    slow   pulse,  and   for  contusion    the  well-marked 

focal  signs,  are  most  characteristic. 

Simple  fractures,  not  combined  with  any  cerebral 
injuries,  usually  heal  within  four  weeks.  In  commo- 
tion perfect  recovery  generally  takes  place  also.  But 
in  compression  caused  by  hemorrhage  from  the  arteria 
meningea  media  the  result  is  fatal  in  the  great  major- 
ity of  cases.  In  contusion  perfect  recovery  may  also 
take  place,  if  the  extent  of  the  lesion  is  quite  limited  ; 
but  in  by  far  the  greater  majority  of  cases  grave  func- 
tional disturbances  remain  or  an  abscess  forms.  Epi- 
lepsy, defective  memory,  and  even  insanity  may  de- 
velop. Epileptiform  symptoms  may  be  caused  by  pres- 
sure conveyed  by  protruding  bone-tissue  in  badly 
wasted  fractures. 

The  treatment  varies  according-  to  the  character  of 
the  injury.  Simple  fractures  heal  without  any  treat- 
ment. In  commotion  a  stimulating  therapy,  such  as 
is  employed  in  shock,  is  indicated.  The  author 
recommends  especially  for  this  purpose  the  methodic 
and  frequent  hypodermic  infusions  of  normal  salt 
17 


258  FRACTURES    OF    SPECIAL    REGIONS. 

solution.     The  subcutaneous  injection  of  camphorated 
oil  and  atropin  is  also  advisable. 

Grave  cranial  injuries  require  the  most  rigorous 
operative  interference.  In  compression  temporary  re- 
section, followed  by  the  removal  of  the  blood-clots  and 
ligation  of  the  arteria  meningea  media,  must  be  per- 
formed   without   delay.      In    open   fractures   the   most 


Fig.  159. — Transverse  fracture  of  frontal  bone,  sustained  fifteen  years  ago  by  a 
man  twenty-five  years  of  age.      (Compare  Fig.  161.) 

thorough  asepsis  (see  p.  51,  on  Compound  Fractures) 
is  required.  Especial  care  has  to  be  taken  in  remov- 
ing all  foreign  bodies — as,  for  instance,  bone-splinters  ; 
also  hairs  that  may  have  been  carried  along  with  the 
foreign  body,  since  they  are  effective  carriers  of  infec- 
tion. The  dura  mater  must  always  be  thoroughly 
exposed. 


FRACTURES    OF     THE    SKULL.  259 

Of  course,  bone-splinters  can  be  removed  only  when 
the  external  opening-  is  sufficiently  wide.  For  widening 
the  opening  different  means  may  be  employed :  A 
chisel  and  cutting  bone-forceps  are  used  for  enlarging 
the  fractured  area.  (See  Fig.  164.)  When,  after 
thorough  exposure,  a  splinter-fragment  or  a  foreign 
body  is  located,  it  is  seized  with  forceps  and  carefully 
extracted.  (Fig.  163.)  If  a  fragment  is  tightly  ad- 
herent to  the  dura  mater,  it  should  never  be  extracted 
by  force,  but  must  be  liberated  by  incising  the  dura 
mater.     An    impacted    fragment  is   relieved    best   by 


Fig.  160.  —  Formation  of  fla 


P- 


making  an  additional  opening  in  the  immediate  vicinity 
(Fig.  165)  in  order  to  introduce  a  lever  there  which 
permits  of  thorough  lifting.  Depressed  fragments  the 
connection  of  which  with  the  periosteum  is  well  pre- 
served are  simply  lifted  with  a  periosteal  elevator. 

If  the  bone  is  intact,  or  if  there  is  only  a  fissure,  or 
in  case  a  fracture  with  little  depression  is  present,  or 
if  a  small  foreign  body  is  to  be  extracted,  the  old  trepan 
or  an  electric  saw  is  to  be  preferred.  The  ingenious 
apparatus  advised  by  Seneca  D.  Powell  (Fig.  162)  is 
especially  useful  in  such  cases. 

In   suitable  cases  the  osteoplastic   resection   of  the 


2  60  FRACTURES    OF    SPECIAL    REGIONS. 

skull  can  be  done  by  forming  a  bone-Hap.  The  technic 
of  this  operation  consists  in  dissecting  the  soft  tissues 
down  to  the  periosteum  in  the  form  of  a  Greek  Q.  (Figs. 
1 60,  161.)  The  edges  of  the  flap  will  retract  some- 
what.    At  the  margin  of  the  skin-flap  the  periosteum 


Fig.  161. — Osteoplastic  resection,  showing  scar  produced  l>y  the  injury,  and  also 
line  of  incision  for  osteoplastic  resection  in  case  illustrated  by  figure  159. 

is  incised  and  a  groove  is  chiseled  into  the  bone  in  the 
same  line  in  which  the  bone-flap  had  retracted.  The 
groove  can  also  be  formed  by  Powell's  saw.  (Fig. 
162.) 

The  groove  should  be  made  in  an  oblique  direction 


FRACTURES    OF    THE    SKULL 


26l 


so  that  the  outer  table  rests  on  the  inner  when  it  is 
returned  again  into  place. 

If  an  elevatorium  is  introduced  underneath  the 
bone-flap,  the  latter  can  be  raised  and  infracted,  so  that 
the  whole  flap  may  be  turned  back,  the  soft  tissues  serv- 
ing- as  a  hinge. 

In  all  operations  in  the  skull  the  incisions  should  be 
made  longitudinally  whenever  possible,  according  to 
the  direction  of  the  arterial  branches.     If  a  transverse 


Fig.  162.  —  S.  D.  Powell  electric  saw. 


(T-shaped)  incision  must  be  added,  the  upper  end  of 
the  longitudinal  incision  should  be  selected  for  it,  since 
the  arteries  are  so  much  smaller  the  nearer  they  are  to 
the  vertex. 

It  goes  without  saying  that  the  same  principles 
apply  to  the  flap  operation. 

In  suppurative  meningitis,  in  encephalitis,  or  in  cere- 
bral abscess  free  exposure  of  the  foci  is  always  indi- 
cated. 


262 


FRACTURES    OF    SPECIAL    REGIONS. 


Skiagraphy  is  of  great  value  in  fractures  of  the  ver- 
tex.    In  the  case  illustrated  by  figures    159  and   161 


Fig.  163. — Removal  of  deep-seated  splinters,  a,  Extracting  forceps  ;  /', 
superficial  and  depressed  splinters;  c,  deep-seated  bone-splinter;  d,  bone-mar- 
gin from  which  the  splinters  were  removed ;   e,  reversed  skin-flap. 


Fig.  164. — Enlarging  fractured  area  by  cutting  forceps,  a,  Protruding  bone- 
portion  to  be  removed  by  forceps;  b,  lacerated  dura  mater  ;  c,  intact  dura  mater; 
d,  wound-margin  of  injured  bone ;  e,  reversed  skin-flaps  ;  f,  cutting  forceps. 

the  depression  of  the  outer  and  the  protrusion  of  the 
inner  table  could  be  well  demonstrated  bv  the  author. 


JUST  ISSUED. 
THIRD  EDITION,  THOROUGHLY  REVISED. 


A    TEXT-BOOK 


PRACTICE  OF  MEDICINE 


BY 

JAMES  M.  ANDERS,  M.D.,  PH.D.,  LL.D. 

Professor  of  the    Practice   of  Medicine  and   of  Clinical    Medicine   in   the    Medico- 

Chirurgical  College,  Philadelphia;  Attending  Physician  to  the  Medico- 

Chirurgical  and   Samaritan  Hospitals,  Philadelphia,  etc. 

A  Magnificent  Octavo  Volume  of  \  287  Pages.     Illustrated 
with  Four  Colored    Plates   and    Numerous  Engravings* 

Prices:  Cloth,  $5.50  net;  Sheep  or  Half  Morocco,  $6.50  net. 

(^*    (^*    (^* 

PRESS   NOTICES. 

"  It  is  a  wgrk  by  which  many  will  profit,  for  it  is  both  comprehensive  and  reliable. 
The  work  of  Dr.  Anders  is  a  good  one." — New  York  Medical  Journal. 

"  The  book  is  a  good  one,  and  for  the  average  general  practitioner  will  be  of  dis- 
tinct service  for  its  detail  of  treatment." — Bulletin  of  the  Johns  Hopkins  Hospital. 

"  Dr.  Anders  has  produced  a  very  creditable  book — one  that  has  come  to  stay 
and  deserves  a  wide  distribution." — Canada  Medical  Record. 

"We  have  gone  over  the  book  carefully  and  with  much  pleasure.  We  thank  the 
author.  We  feel  that  he  has  added  to  our  literature  a  book  of  real  value — a  thoroughly 
useful  book." — Brooklyn  Medical  Journal. 

"  For  clearness  of  method,  conciseness  of  expression,  continuity  and  crystalline 
clearness  of  thought,  we  have  never  seen  its  equal  from  the  pen  of  an  American 
author.  It  has  never  been  our  lot  to  more  heartily  commend  and  praise  a  book." — 
Georgia  Journal  of  Medicine  and  Surgery. 

"It  is  an  excellent  book,  thoroughly  up  to  date,  and  a  reliable  guide  to  the 
general  practitioner."— Canadian  Practitioner. 

t£*  &?*  &?* 

Sent  postpaid  on  receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

(see  other  side)  925  Walnut  Street,  Philadelphia,  Pa. 


Anders'  Practice  of  Medicine, 


PROFESSIONAL  COMMENTS. 


'It  is  an  excellent  book, --concise, 
comprehensive,  thorough,  and  up  to  date, 
It  is  a  credit  to  you;  but,  more  than 
that,  it  is  a  credit  to  the  profession 
of  Philadelphia--to  us." 


^./^/W 


Professor  of  the  Practice  of  Medicine  and  of  Clinical  Medici** 
fefferson  Medical  College,  Philadelphia. 


"I  consider  Dr.  Anders'  book  not 
only  the  best  late  work  on  Medical  Prac- 
tice, but  by  far  the  best  that  has  ever 
been  published.   It  is  concise,  system- 
atic, thorough,  and  fully  up  to  date 
in  everything.   I  consider  it  a  great 
credit  to  both  the  author  and  the  pub- 
lisher .  " 

President  qf  Ike  Illinois  Homeopathic  Medical  Association 


FRACTURES    OF    THE    SKULL. 


26 


As  the  patient  suffered  from  epileptiform  attacks  after 
the  injury,  which  was  originally  taken  for  a  superficial 
lesion  only,  osteoplastic  resection  was  performed  fif- 
teen years  later.  The  condition  found  at  the  opera- 
tion verified  the  correctness  of  the  skiagraph  entirely. 
The  attacks  have  since  stopped  (time  of  observation 
after  operation,  one  year). 

The  extracranial  as  well  as  the  intracranial  location 
of  bullets  has  ceased  to  offer  technical  difficulties.     If 


Fig.  165. — Relieving  of  impacted  fragment,  a,  Fragment  ;  b,  elevator  ;  c, 
dura  mater ;  J,  opening  trephined  for  introduction  of  lever ;  e,  trephined  open- 
ing ;  f,  reversed  skin-flap. 


bullets  are  situated  in  the  bones,  two  skiagraphs  at 
least  are  required — one  to  be  taken  anteriorly  or  pos- 
teriorly and  the  other  laterally.  By  simply  crossing 
their  diameters  diagonally  the  distance  from  the  outer 
surface  can  be  determined.  The  same  principles  of 
localization,  more  or  less  modified,  apply  to  the  intra- 
cranial localization  of  bullets. 

In  extracting-  a  bullet  the  author  found  it  useful  to 
measure  the  distance  of  the  bullet  from   the  nearest 


264 


FRACTURES    OF    SPECIAL    REGIONS. 


bone  prominence  in  both  skiagraphs  ;  also  to  compare 
the  skiagraph  with  the  features  of  a  normal  skull. 

In  the  case  illustrated  by  figure  1 58  a  bullet  had 
entered  the  right  temporal  region,  and,  by  passing  the 
orbit  transversely,  caused  traumatic  enophthalmos 
(injury    of    the    sympathetic    roots    of    the    ganglion 


Fig.  K 


-Fracture  of  the  base  of  the  skull. 


ciliare?).  The  optic  nerve  was  pierced  and  consider- 
able hemorrhage  of  the  choroidea  and  retina  had  taken 
place.  Neither  the  comminution  of  the  orbit  nor  any 
injury  within  the  extent  of  the  left  antrum  Highmori, 
through  which  the  bullet  had  taken  its  course,  could 
be  demonstrated  by  the  rays,  but  the  bullet  itself  was 


FRACTURES    OF    THE    SKULL.  265 

located  in  the  left  pterygoid  process.  The  distances 
were  measured  during  operation  simply  with  a  graded 
probe  first,  the  distance  between  the  nasal  bone  and 
the  bullet  being  taken  at  the  first  skiagraph,  which 
determined  the  direction  and  extent  of  the  skin  inci- 
sion, and  then  the  same  distance  being  taken  from  the 
side  skiagraph,  which  dictated  the  depth  of  the  inci- 
sion. Although  the  bullet  was  embedded  in  the  bone 
and  was  surrounded  by  new  bone-tissue,  it  was  not 
difficult  to  detect  and  extract  it,  after  the  antrum 
Highmori  had  been  exposed  by  osteoplastic  resection 
of  its  anterior  wall.  Without  the  aid  of  the  rays  it 
would  have  been  impossible  to  trace  the  bullet.  In 
fact,  it  was  a  surprise  to  the  author  that  it  had  taken 
so  lone  and  destructive  a  course  without  showing- 
any  other  symptoms  than  a  dull  continuous  pain  all 
over  the  skull. 

The  bullet  was  so  much  compressed  that  it  had 
altered  its  longitudinal  form  into  a  flat  disc,  which  ex- 
plains the  shape  of  the  bullet  in  the  skiagraph. 


FRACTURES  OF  THE  BASE  OF  THE  SKULL 

(Fig.  166)  are,  with  the  exception  of  gunshot  fractures, 
always  caused  by  indirect  violence  (fall,  blow).  In 
many  instances  a  fissure  only  is  produced,  the  seat  of 
predilection  being  the  lateral  margins  of  the  foramen 
occipitis.  From  there  the  fractures  often  radiate 
toward  the  sphenoid  and  the  squamous  portion  of  the 
temporal  bone. 

Most  fractures  of  the  base  are  simple  continuations 
from  the  vertex,  the  force,  for  instance,  being  applied 
to  the  forehead  and  the  fracture  radiating  to  the  base. 


266 


FRACTURES    OF    SPECIAL    REGIONS. 


Strictly  local  signs  are  absent ;  a  fact  which  is  well 
explained  by  the  concealed  situation  of  the  fractured 
area. 

Signs. — Among  the  general  or  indirect  signs  the 
most  important  one  is  hemorrhage  from  one  ear  or 
from  both  ears  in  consequence  of  the  fracture  of  the 
petrous  portion  of  the  temporal  bone  and  the  simulta- 


Fig.  167. — Fracture  of  the  nose,  showing  considerable  upward  displacement,  in  a 
man  twenty-eight  years  of  age  (two  days  after  the  injury). 


neous  laceration  of  the  tympanum.  Sometimes  hem- 
orrhage from  the  nose  (ethmoidal  bone)  and  pharynx 
(sphenoid  body)  are  also  observed. 

If  the  fracture  is  situated  far  anteriorly,  sometimes 
ecchymosis  develops  gradually  in  the  ocular  region, 
especially  in  the  bulbar  conjunctiva.  In  case  of  con- 
siderable blood  extravasation  there  is  also  slight 
exophthalmos. 


FRACTURES    OF     THE    SKULL.  267 

Sometimes  there  is  a  considerable  escape  of  cere- 
brospinal fluid,  the  reaction  of  which  is  most  character- 
istic, inasmuch  as  it  shows  the  presence  of  sugar,  of 
small  quantities  of  albumin,  and  of  a  large  amount  of 
salt. 

There  is  often  paralysis  of  the  facial,  auditory,  oculo- 
motor, trochlear,  and  abducens  nerves  (strabismus). 
A  thorough  examination  with  the  ophthalmoscope  not 
infrequently  reveals  conditions  explained  by  the  pres- 
ence of  blood  extravasation  in  the  sheath  of  the  optic 
nerve,  which  is  often  produced  by  fractures  within  the 
extent  of  the  optic  canal." 

There  may,  besides,  be  those  signs  of  cerebral  com- 
motion, compression,  and  contusion  that  have  been  dis- 
cussed in  connection  with  fractures  of  the  vertex.  (See 
p.  252.) 

So  far  skiagraphy  could  be  relied  upon  in  this  frac- 
ture type  only  if  the  injury  was  well  marked  and  was 
situated  anteriorly. 

The  prognosis  of  fractures  of  the  base  is  extremely 
unfavorable  ;  infection,  as  well  as  destruction  of  vital 
areas  within  the  brain,  producing  fatal  meningitis  or 
encephalitis.  In  tjbe  rare  event  of  recovery  there 
usually  remains  paralysis  within  the  extent  of  the 
injured  nerve  sphere. 

From  an  anatomic  consideration  of  the  fractures  of 
the  base  it  becomes  necessarily  evident  that  they  are 
beyond  direct  surgical  reach.  The  treatment  must  be 
conducted  upon  general  principles,  rest  and  artificial 
feeding  beinpf  the  main  factors  to  be  considered.  The 
discharge  of  blood  and  of  cerebrospinal  fluid  must  be 
watched.  The  meatus  should  not  be  irrigated,  but 
must  be  protected  with  a  thick  idoform  gauze  dressing, 


2  68  FRACTURES    OF    SPECIAL    REGIONS. 

which  is   kept  well   saturated  with  a  strong  bichlorid 
solution. 

The  treatment  of  the  cerebral  symptoms  falls 
under  the  same  considerations  as  those  that  have  been 
treated  of  under  fracture  of  the  vertex.      (See  p.  257.) 


FRACTURES  OF  THE  FACIAL  BONES 

are    mainly    those    of    the   nasal   bones,  the   superior 
maxilla  with  the  zygoma,  and  the  inferior  maxilla. 

Fractures  of  the  nasal  bones  (Fig.  167)  are 
caused  by  direct  violence  (sometimes  by  a  fall  upon  the 
nose  ;  more  frequently,  by  a  blow  with  the  fist  or  a  stick). 
In  far  the  greater  majority  of  cases  the  nasal  bones 
themselves  and  the  vomer,  but  sometimes  also  the 
nasal  processes  of  the  superior  maxilla,  as  well  as  of 
the  frontal  bone,  are  involved.  Very  rarely  fractures 
of  the  lacrimal  and  turbinated  bones  and  of  the  cribri- 
form plate  of  the  ethmoid  bone  are  observed. 

In  children  fracture  of  the  nasal  bones  is  often 
caused  by  diving  into  shallow  water. 

The  signs  consist  in  ecchymosis  of  the  nasal  dorsum  - 
and  in  more  or  less  profuse  hemorrhage  from  the 
nasal  cavities.  There  is  always  backward  displace- 
ment of  the  fragments,  so  that  the  shape  of  the  nose 
becomes  flattened  (traumatic  saddle-nose).  If  the 
vomer  participates,  lateral  displacement  of  the  nasal 
frame  is  also  produced. 

The  extensive  ecchymosis  often  veils  the  nature  of 
this  injury.  If  a  fracture  is  suspected,  anesthesia  is 
advisable. 

The  treatment  consists  in  exact  reposition,  which  is 
best  accomplished  in  the  following  manner:  A  dress- 


FRACTURES    OF     THE    SKULL.  269 

ing  forceps,  the  branches  of  which  are  kept  closed,  is 
introduced  and  pushed  against  the  inwardly  displaced 
fragments.  The  manipulations  of  the  forceps  are 
controlled  from  without  by  gently  pressing  the  fingers 
of  the  left  hand  on  the  nasal  dorsum.  If  there  should 
be  very  much  displacement,  reposition  must  be  tried 
by  introducing  the  forceps-branches  separately  and 
then  compressing  the  septum  in  such  a  manner  that 
the  deformity  becomes  corrected.  The  reduced  frag- 
ments are  kept  in  situ  by  "intranasal  splints,"  which 


Fig.  168. — Dental  splint. 

should  consist  of  rubber  drains.  They  are  retained 
by  packing  iodoform  gauze  around  them  and  are 
secured  by  small  safety-pins.  If  the  latter  are  affixed 
to  the  drain-ends,  just  where  they  emerge  from  the 
nasal  cavities,  they  serve  as  a  supporting  bridge,  held 
in  place  best  by  rubber  adhesive-plaster  strips. 

If  union  should  have  so  taken  place  as  to  produce 
deformity,  correction  can  be  made  by  separating  the 
old  fracture-lines  again  with  small  chisels  and  nasal 
bone-forceps.     The  traumatic  saddle-nose  can  only  be 


27O  FRACTURES    OF    SPECIAL    REGIONS. 

corrected    by    partial    rhinoplasty,    as    suggested    by 
Czerny. 

Fractures    of  the    superior    maxilla    and    the 


Fig.  169. — Fracture  of  the  alveolar  process,  caused  by  a  fall  from  a  locomotive  on 
a  rail,  producing  great  functional  disturbance  ;   man  fifty  years  of  age. 

zygoma  are  caused  by  direct  violence  (blow  by 
heavy  and  blunt  force — stone,  club,  base-ball,  horse- 
hoof). 

The    signs   are    always    well    marked  ;    depression, 


FRACTURES    OF    THE    SKULL. 


271 


abnormal  mobility,  and  crepitus  being  present.  The 
line  of  fracture  may  be  either  vertical  or  transverse. 

The  most  frequent  type  is  the  fracture  of  the  alveo- 
lar process,  in  which  the  fragments  are  driven  toward 
the  oral  cavity.  They  sometimes  remain  in  loose  con- 
nection with  the  maxilla,  being  attached  by  a  small 
bridge  of  alveolar  tissue.      (Fig.  169.) 

The  treatment  in  all  instances  consists  in  reposition, 
except  where  the  fragment  is  impacted  between  the 
adjoining  bones.     External  wounds  being  present  in 


Fig.  170. — Transverse  fracture  of  zygoma,  caused  by  a  fall  from  a  carriage  upon 
the  edge  of  the  sidewalk,  in  a  man  of  thirty -five  years. 

the  greater  majority  of  cases,  it  is  evident  that  great 
attention  must  be  directed  to  thorough  asepsis.  In 
gunshot  wounds  the  extraction  of  splinters  has  to  be 
considered. 

Graefe's  head-band,  which  holds  the  alveolar  pro- 
cess on  a  grooved  steel  bar,  was  formerly  the  favorite 
immobilizing  medium,  but  modern  practice  gives  the 
preference  to  a  dental  splint.     (Fig.  168.) 

Fracture  of  the  zygoma  (Fig.  170)  without  displace- 
ment should  simply  be  treated  by  rest.  But  if  the 
zygomatic  arch  is  entirely  severed  from  its  connections 


272 


FRACTURES    OF    SPECIAL    REGIONS. 


with  the  maxilla  and  from  the  frontal  and  temporal 
bones,  the  considerable  displacement  resulting  there- 
from requires  thorough  reposition.  In  such  cases  the 
injury  may  extend  to  the  orbit.  The  author  observed 
a  case  in  which  pressure  of  the  depressed  zygomatic 
fragment  had  caused  comminution  of  the  orbit,  fol- 
lowed by  intracranial  abscess  formation. 


Fig.   171. — Fracture  of  the  inferior  maxilla. 


Fractures  of  the  inferior  maxilla  (Fig.  171)  are 
frequent,  and  concern  its  arch  in  the  great  majority 
of  cases.  They  are  always  caused  by  direct  violence 
(blow — horse-hoof,  stone — or  gunshot  wound).  By  in- 
direct violence  (fall  on  the  chin  or  simultaneous  com- 
pression of  both  mandibular  angles)  they  are  produced 
but  rarely. 


FRACTURES    OF     THE    SKULL.  273 

In  children  they  are  uncommon. 

The  head,  neck,  and  coronoid   process  of  this  bone 
are  but  seldom  fractured. 

The  signs  are  always  well   marked.     There  is  con- 


Fig.  172. — Fracture  of  mental  portion  of  the  inferior  maxilla  in  a  girl  of  eleven 
years,  well  united,  four  weeks  after  the  injury. 

siderable    displacement    and     functional     disturbance. 
Mastication    is    impossible,     deglutition    becomes    im- 


2  74        FRACTURES  OF  SPECIAL  REGIONS. 

paired,  and  articulation  is  indistinct.  The  saliva  is 
profusely  discharged  from  the  oral  cavity,  which  is 
generally  kept  wide  open. 

The  treatment  consists,  first  of  all,  in  exact  reposition. 
Immobilization  is  best  accomplished  then  by  dental 
splints  made  of  gold  or  aluminium  molded  after  a 
plaster-of-Paris  cast.  (Compare  Fig.  1 68.)  If  there  be 
but  little  tendency  to  displacement,  the  fragments  can 
sometimes  be  kept  together  by  winding  silver  wire 
around  the  nearest  teeth.  In  such  cases  a  supporting 
splint  of  moss-board,  which  surrounds  the  whole  exter- 
nal surface  of  the  mandibular  area,  does  good  service. 
(See  p.  66.) 

In  the  absence  of  teeth  wiring-  of  the  fragments  has 
to  be  resorted  to.      (See  p.  69.) 

Since  these  fractures  are  of  a  compound  character, 
the  alveolar  tissues  always  being  more  or  less  injured, 
great  attention  must  be  given  to  the  most  rigid  obser- 
vation  of  aseptic  principles.  Accordingly,  careful  clean- 
ing of  the  teeth,  frequent  application  of  a  disinfecting 
mouth-wash  (salicylic  acid,  0.2  per  cent.),  and  iodoform 
gauze  packing  of  the  wound-cavities  are  the  main 
therapeutic  factors. 

The  diet  should  be  liquid  until  union  becomes  per- 
fect. 

If  asepsis  is  not  carried  through  in  the  most  rigid 
manner,  infection  may  cause  suppurative  periostitis 
and  osteomyelitis,  followed  by  bone-necrosis.  It 
should  be  remembered  that  in  oral  suppurations  the 
respiratory  organs  are  constantly  exposed  to  the  dan- 
ger of  infection,  many  cases  of  non-complicated  frac- 
tures of  the  inferior  maxilla  having  ended  fatally  on 
account  of  pneumonia  (Schluckpneumonie). 


FRACTURES    OF    THE    SKULL.  275 

Fracture  of  the  Larynx. — Fracture  of  the  larynx 
is  peculiar  to  the  age  beyond  forty,  that  being-  a  period 
of  life  in  which  the  laryngeal  cartilages  begin  to  calcify. 
The  injury  in  question  affects  the  thyroid  cartilage  in 
the  great  majority  of  cases,  fractures  of  the  cricoid 
and  arytenoids  being  extremely  rare.  It  is  nearly 
always  caused  by  direct  violence  (blow  while  wrest- 
ling, attempted  strangling). 

Fracture  of  the  thyroid  cartilage  may  be  either  uni- 
lateral or  bilateral. 

The  signs  consist  in  ecchymosis,  in  more  or  less  de- 
formity, and  in  abnormal  mobility.  Crepitus  is  gener- 
ally absent,  but  there  is  always  functional  disturbance, 
the  severity  of  which  may  vary  from  slight  discomfort 
to  dysphagia  and  dyspnea.  Laryngoscopy  generally 
reveals  laceration  in  the  mucous  membrane  and  sub- 
mucous hematoma. 

The  treatment  must  especially  take  into  account  the 
dangers  of  dyspnea.  Intubation  should  be  performed 
without  delay.  When  there  is  considerable  displace- 
ment of  fragments,  causing  endolaryngeal  extravasa- 
tion and  consequent  edema,  tracheotomy  should  be 
resorted  to.  In  the  treatment  of  the  sequelae  cica- 
tricial stenosis  has  to  be  mainly  considered.  If  such  a 
stenosis  should  supervene,  the  permanent  employment 
of  a  tracheal  tube  will  become  necessary. 

Fracture  of  the  Hyoid  Bone. — Fracture  of  the 
hyoid  bone  is  produced  by  the  same  causes  as  that  of 
the  larynx.  It  generally  takes  place  at  the  junction  of 
the  corpus  with  the  cornu   majus. 

The  signs  are  also  similar  to  those  of  fracture  of 
the  larynx,  but  they  are  usually  much  less  severe, 
slight  hemorrhage  from  the  mouth,  hoarseness,  painful 


276  FRACTURES    OF    SPECIAL    REGIONS. 

articulation,  and  deglutition  being  generally  present. 
Sometimes  dyspnea  becomes  considerable. 

The  treatment  consists  in  manual  reposition,  the 
surgeon's  left  index-finger  reducing  the  fragment  while 
counterpressure  is  exerted  from  the  outside  by  the 
right  index-finger  and  the  thumb.  If  reposition  can 
not  thus  be  accomplished,  an  external  incision  must 
be  made  upon  the  fragment,  which  can  then  invariably 
be  reduced  by  a  sharp  tenaculum,  which  secures  it 
during  the  reducing  manipulations. 

The  patient  must  be  fed  by  means  of  an  esophageal 
tube  for  at  least  two  weeks,  and  should  be  directed  to 
keep  silent. 


APPENDIX. 


THE    PRACTICAL    USE    OF   THE 
RONTGEN  RAYS. 

The  art  of  skiagraphy  can  be  mastered  only  after  a 
thorough  study  of  the  numerous  details  of  the  various 
apparatus  necessary  for  the  production  of  the  Ront- 
gen  rays.  Its  two  first  and  greatest  essentials  are  a 
high  electric  current  and  a  Rontgen  vacuum  tube. 

A  high  current  can  be  obtained  in  different  ways. 
At  present  three  forms  of  mechanism  are  more  or 
less  in  use  :  viz.,  the  Ruhmkorff,  a  simple  form  of  in- 
duction coil  ;  the  Tesla,  or  hig-h-tension  induction  coil, 
and  the  static  machine.  The  most  efficacious  for 
skiagraphic  work  is  the  Ruhmkorff  induction  coil, 
which  is  excited  by  means  of  a  current  derived  either 
from  a  battery  or  from  a  so-called  direct  current  (city 
supply).  A  suitable  battery,  which  furnishes  a  steady 
current,  is  the  so-called  Edison-Lalande  cell-battery. 
For  use  when  traveling,  storage  batteries  may  be  pre- 
ferred, the  great  trouble,  however,  being  that  if  they 
become  exhausted  at  a  distance  from  a  city,  they  can 
not  be  recharged,  while  the  Edison-Lalande  cells  can 
be  recharged  anywhere. 

The  direct  current,  of  course,  is  far  superior  to  any 
other  source,  since  there  is  neither  charging  nor  super- 
vising- necessarv.      And,  last  but  not  least,  the   direct 

277 


278 


APPENDIX. 


current  never  embarrasses  the  operator  by  proving-  to 
be  inefficient.      Accordingly,   whenever  possible,   COn- 


Fig-  173- — >',   Rheostat;   /,  lever;  s,   adjustable  stand;   //,  handle;  w,   wheel  of 
motor  apparatus  ;  a,  anode ;   c,  cathode. 


nection  with  the  1 10-  or  120- volt  direct  current  should 
be  made. 


PRACTICAL    USE    OF    RONTGEN    RAYS.  279 

The  stronger  the  coil,  the  more  efficacious  the  rays, 
as  a  rule.  While  good  skiagraphs  can  be  obtained  by 
small  apparatus  that  give  a  spark  of  the  length  of  only 
six  inches,  in  general  large  coils  giving  a  spark-length 
of  from  14  to  15  inches  are  to  be  preferred.  An  in- 
ductor of  this  power,  with  a  i  io-volt  direct  current, 
should  afford  a  current-strength  of  from  i  to  2  am- 
peres. 

The  reliability  of  a  Rukmkorff coil  (Fig.  1 73)  depends 
upon  its  thorough  construction,  and  especially  upon  the 
proper  quality  of  the  wires  and  the  accurate  proportion 
of  the  windings  of  the  primary  and  secondary  coils.  Of 
special  importance  is  the  thorough  insulation  of  the 
primary  from  the  secondary  coil,  since  any  leakage 
would  cause  sparking,  and  would  consequently  destroy 
the  coil. 

Into  the  interior  of  the  coil  a  condenser  is  placed  for 
the  purpose  of  intensifying  the  result. 

If  the  apparatus  is  used  in  connection  with  a  battery, 
a  vibrator  must  be  adjusted,  which  controls  the  peri- 
odicity of  the  vibrations.  If  attached  to  the  direct 
current,  the  air-brake  wheel  should  be  used,  which 
renders  the  use  of  a  vibrator  unnecessary.  The  air- 
brake wheel  attachment  (Fig.  173,  w)  permits  great 
rapidity  of  change  in  the  electric  circuit,  thus  intensify- 
ing the  electromotive  force  in  the  secondary  coil.  It 
consists  of  two  tooth-wheels,  the  projections  of  which  are 
brought  into  close  contact  with  two  flat  brushes,  which 
lead  the  current  in  and  out,  while  the  dentated  wheels 
are  rotated  at  a  high  speed  by  a  small  motor.  This 
motor  runs  a  pressure-blower  at  the  same  time,  the 
air-blast  from  which  is  directed  to  a  two-forked  tube, 
through  which   it  is  led  out  again  by  two  flat  nozles 


280  APPENDIX. 

placed  directly  above  the  brushes.     There  the  spark  is 
blown  out  again  by  the  air-blast  as  soon  as  it  forms. 

The  current  passing-  through  the  coil  is  controlled 
by  a  rheostat.  (Fig.  173,  r.)  By  combining  this  with 
the  air-brake  wheel  apparatus  the  electromotive  force 
in  the  secondary  coil  is  augmented  much  more  than  it 
would  be  with  a  simple  motor  apparatus  controlled  by 
a  shunt-board  provision. 

The  best  electric  apparatus  are  made  in  this  country. 
The  alternating  current,  which  is  used  almost  exclus- 
ively in  Europe,  requires  more  complicated  apparatus, 
so  that  its  handling  presupposes  the  experience  of  a 
professional  electrician. 

The  most  important  factor,  and  the  one  upon  the 
efficiency  of  which  the  success  of  skiagraphy  largely 
depends,  is  the  tube :  the  higher  its  vacuum,  the  more 
powerful  and  penetrating  the  Rontgen  rays. 

The  Rontgen  tube  (Fig.  173)  consists  of  a  glass 
vessel,  usually  of  an  oblong  or  globular  shape,  from 
which  the  air  is  exhausted  and  into  which  the  ends  of 
electrodes  are  fused.  With  suitable  exhaust  pumps 
the  rarefaction  of  the  air  in  the  tube  can  be  brought 
as  high  as  one-millionth  part  of  the  ordinary  density. 
One  of  the  electrodes  ends  in  a  disc  of  globular 
concave  shape,  which  is  made  of  aluminium  ;  this 
electrode  is  called  the  cathode.  (Fig.  173,  c.)  The 
other  ends  in  a  disc  of  fiat  shape,  which  is  of  plati- 
num ;  this  is  called  the  anode.  (Fig.  173,  a.)  The 
anode  is  situated  opposite  the  cathode  at  an  angle 
of  about  forty-five  degrees.  Its  shape  may  be  cir- 
cular as  well  as  square.  Almost  all  of  the  modern 
tubes  also  contain  a  second  anode,  which  is  connected 
with  the  main  anode  (platinum).      (Fig.  173,  a.) 


PRACTICAL    USE    OF    RONTGEN    RAYS.  251 

One  of  the  great  difficulties  encountered  in  the  use 
of  the  tubes  is  due  to  their  soon  becoming-  inefficient 
on  account  of  the  permanent  change  of  pressure  that 
occurs  within  them. 

In  view  of  this  variation  of  the  intratubal  pressure, 
tubes  have  been  constructed  that  permit  lowering  and 
raising  of  the  vacuum  in  the  tube  at  will.  Siemens 
found  that  the  fluorescing  air,  with  the  vapors  of  phos- 
phorus, iodin,  and  other  similar  substances,  forms 
dense  bodies,  thereby  diminishing  the  pressure  within 
the  tube.  On  the  other  hand,  if  the  walls  of  the 
tube  are  warmed,  the  stratum  of  air  that  condenses 
on  the  glass  surface  is  driven  away,  thereby  intensi- 
fying the  pressure.  In  utilizing  this  principle  tubes 
with  adjustable  vacuum  have  been  constructed,  which 
are  provided  with  an  adjuster  intensifying  and  dimin- 
ishing the  vacuum  at  will  by  lengthening  and  shortening 
the  space  between  its  spark-rods. 

If  currents  of  very  high  intensity  are  used,  the  plati- 
num disc  of  almost  all  tubes  becomes  white  hot  after 
a  short  time  (often  after  a  few  seconds).  If  thus  kept 
glowing  a  little  longer,  the  platinum  melts.  To  ob- 
viate this  most  embarrassing  occurrence,  tubes  have 
recently  been  constructed  in  which  the  metallic  parts 
are  very  thick  and  resistant.  Such  tubes  permit  of 
a  current  of  maximum  intensity  for  about  one 
minute ;  then  the  very  marked  outlines  of  the  pic- 
ture become  less  distinct,  the  tube  filling-  with  blue 
light  at  the  same  time,  which  indicates  that  it  is 
overheated  ;  the  current  must  then  be  turned  off  with- 
out delay.  Such  tubes  make  a  good  skiagraph  of 
the  thorax,  for  instance,  in  forty-five  seconds.  Grun- 
mach  constructed  tubes  that  permit  the  glowing  metal 


252  APPENDIX. 

to  be  cooled  by  the  intratubal  circulation  of  a  stream 
of  cold  water. 

The  best  tubes  are  undoubtedly  those  that,  when 
just  purchased,  show  a  red-hot  focus  at  the  platinum 
disc  while  a  low  current  is  employed.  New  tubes  that 
show  fluorescence  only  by  using  a  high  current  should 
invariably  be  rejected.  It  is  one  of  the  main  character- 
istics of  a  orood  tube  that  it  stands  intense  trlowine  of 
the  platinum  disc  without  being  impaired  at  once  ;  in 
other  words,  that  it  stands  currents  of  high  intensity. 
A  "food  tube  must  also  furnish  a  uniform  liofht. 

The  variety  of  tubes  manufactured  now  in  various 
parts  of  the  world  is  very  great.  The  best  are 
made  in  Thuringen  (Germany).  It  requires  a  vast 
amount  of  experience  and  repeated  experimentation 
to  select  tubes  suitable  for  the  particular  apparatus  to 
be  employed.  So  it  must  be  considered  that  static 
machines  require  tubes  with  a  special  vacuum,  while 
tubes  prepared  for  a  battery-set  generally  do  not  give 
satisfaction  with  an  air-brake  wheel  apparatus  or  a 
Wehnelt  interruptor,  which  permits  the  use  of  tubes  of 
the  highest  vacuum  obtainable  at  present. 

The  vacuum  of  the  tubes  is  generally  increased  dur- 
ing their  use,  which  necessitates  a  proportional  increase 
of  the  intensity  of  the  current.  Therefore,  even  for  in- 
ductors furnishing  a  very  long  spark,  tubes  with  a  low 
vacuum  should  be  chosen,  as  the  latter  increases  so 
much  during  use  that  at  last  the  full  power  of  the  appa- 
ratus is  required  for  producing  an  efficient  light.  Fin- 
ally, however,  the  fluorescence  of  the  tube  ceases,  even 
if  the  high  current  is  employed.  Then  the  vacuum 
can  be  reduced  by  heating  the  tube  with  an  alcohol- 
lamp,  while  a  weak  current  is  used,  until  the  fluores- 


PRACTICAL    USE    OF    RONTGEN    RAYS.  283 

cence  becomes  distinct  a^ain.  If  this  fails,  the  tube 
should  be  surrounded  evenly  and  tightly  by  gauze 
compresses  slightly  moistened  with  water. 

At  last,  of  course,  all  these  procedures  will  prove  to 
be  without  avail.  Some  tubes  regain  their  efficiency 
simply  by  being  left  untouched  for  a  few  weeks,  but 
finally  they  all  become  useless  for  medical  purposes. 
Then  the  resistance  of  the  tube  becomes  so  great  that, 
while  the  interior  hardly  shows  any  fluorescence,  most 
of  the  sparks  go  around  the  exterior  surface  of  the 
tube. 

The  presence  of  purple  or  red  light  points  to  a  leak, 
which  naturally  renders  the  tube  inefficient.  Leaky 
tubes  may  be  repaired  by  sealing  the  defect. 

The  tubes  must  be  preserved  in  a  closet  in  which 
there  is  a  uniform  medium  temperature.  They  should 
rest  on  padded  shelves.  Dust,  which  in  the  course  of 
time  always  becomes  adherent  to  the  tube  while  in  use, 
is  to  be  wiped  off  by  passing  the  dry  palm  of  the  hand 
gently  over  it. 

The  degree  of  intensity  of  the  tubal  light  and  the 
amount  of  penetration  can  be  estimated  by  an  experi- 
enced operator  simply  by  holding  his  own  hand  before 
the  fluorescing  screen.  For  exact  measurement,  how- 
ever, various  kinds  of  skiameters  have  been  devised, 
the  principle  of  which  consists  in  the  attachment  of 
small  squares  of  tinfoil,  of  varying  thickness,  to  a  fluor- 
escing screen.  The  difference  of  thickness  is  indicated 
by  little  figures,  made  of  lead,  which  appear  more  or 
less  distinct  according  to  the  thickness  of  their  corre- 
sponding tinfoil.  The  author  found  it  useful  to  con- 
struct a  skiameter  consisting  of  fifty  staniol  discs,  ac- 
cording to  the  number  of  knobs  at  his  rheostat.      (Fig. 


284  APPENDIX. 

173,  r)  To  each  disc  a  number,  made  of  wire,  is 
attached,  which  indicates  the  number  of  the  staniol 
lamellae.  No.  1,  for  instance,  contains  one  lamella 
only,  while  No.  50  contains  fifty.  That  number  which 
just  permits  of  the  recognition  of  the  shade  of  its  wire 
cipher  indicates  the  degree  of  intensity  of  the  tube. 

If  the  rays  fall  upon  a  screen  covered  with  fluores- 
cing salts,  such  as  tungstate  of  calcium,  platinocyanid 
of  potassium,  or  platinocyanid  of  barium,  fluorescence 
is  caused  on  it.  The  human  hand,  for  instance,  if 
placed  between  the  tube  and  a  screen  evenly  covered 
with  one  of  the  fluorescing  salts,  shows  the  condition 
of  its  bones  distinctly.  Even  the  soft  tissues  can  be 
distinguished  to  some  extent. 

The  use  of  the  fluorescing  screen  is  facilitated  by 
attaching  it  to  a  suitable  framework,  formed  like  a  ster- 
eoscope,  the  body  of  which  is  of  tapering  form.  The 
large  end  of  such  an  instrument,  generally  called  flu- 
oroscope,  should  contain  a  piece  of  cardboard,  on  the 
inner  surface  of  which  the  fluorescent  salt  is  distributed, 
while  the  small  end  has  two  apertures,  formed  in  such 
a  manner  as  to  fit  over  the  eyes  of  the  operator. 

With  the  fluoroscope  a  superficial  examination  of 
the  objects  can  be  made.  Movable  organs — as,  for 
instance,  joints,  larynx,  hyoid  bone,  or  the  intrathoracic 
viscera  (especially  the  diaphragm,  heart,  and  pericar- 
dium)— can  be  studied  while  moving  or  pulsating. 
But  the  numerous  fluorescing  impressions,  succeed- 
ing each  other  with  great  rapidity,  are  apt  to  deceive 
the  human  eye  wherever  the  features  of  the  lesion  are 
not  distinctly  marked  ;  while  fixation  on  a  photographic 
plate  gives  all  the  details  exactly.  Therefore,  fluor- 
oscopy should  be  used   in   fractures  as   a  preliminary 


PRACTICAL    USE    OF    RONTGEX    RAYS.  285 

procedure  only.  It  calls  attention  to  the  seat  of  the 
fracture,  and  determines  the  best  position  of  the  limb 
for  proper  fixation.  Especially  in  joint  fractures  it  will 
select  that  angle  of  flexion  or  extension  in  which  the 
injured  portion  can  be  brought  out  best  on  the   plate. 

It  is  the  plate  only  which  shows  the  details  of  the 
fracture  exactly  and  which  permits  of  the  thorough 
study  of  the  various  features  of  the  fracture  type.  Its 
comparison  with  the  normal  skeleton  will  make  the 
abnormalities  evident  at  once  and  will  help  the  sur- 
geon to  a  thorough  judgment  of  the  case  ;  and  the 
value  of  a  skiagraph  for  future  information — some- 
times for  forensic  purposes — should  not  be  underes- 
timated. Therefore,  whenever  exactness  of  result  is 
desired,  fixation  on  a  pliotographic  plate  is  to  be 
preferred."  The  photographic  technic  can  easily  be 
learned. 

The  development  of  a  skiagraphic  plate  is  practi- 
cally the  same  as  that  of  an  ordinary  photographic 
one  exposed  to  sunlight.  There  is  no  doubt  that  the 
anatomic  knowledge  of  a  physician  makes  him  more 
fit  to  develop  the  important  parts  of  a  plate  more  in- 
tensely. It  is,  besides,  a  great  advantage  if  the  phy- 
sician is  able  to  develop  the  plates  himself,  since  he  is 
enabled  to  learn  the  result  at  once,  while  sending  the 
plate  to  a  photographer  involves  a  great  loss  of  time. 

Notwithstanding  this  fact,  the  author,  believing  that  a 
skilled  operator  can  do  more  exact  work  than  the  medi- 
cal amateur,  prefers  to  have  the  valuable  assistance  of 
a  professional  photographer,  and  therefore  has  his 
plates  developed  by  the  most  skilful  experts  available. 

In  taking  skiagraphs  properly  a  number  of  small 
details  should  be  considered.      First  of  all,  it  should 


286  APPENDIX. 

be  borne  in  mind  that  it  is  a  law,  applicable  to  all  ele- 
ments, that  the  higher  their  atomic  weight,  the  more 
energetic  the  absorption  of  the  rays.  The  organic 
substances  of  the  body,  such  as  the  salts  of  lime  in  the 
bones,  absorb  more  light  than  the  surrounding  soft 
tissues,  consequently  they  are  but  slightly  permeable. 
The  more  lime-salts  the  bone  contains,  the  less  perme- 
ability exists  and  the  more  distinct  its  silhouette  will 
be  on  the  photographic  plate.  Compact  bone-tissue 
thus  shows  a  much  more  distinct  picture  than  the 
medullary  or  spongy  parts.  (See  Figs.  1 19  and  135.) 
The  special  structure  of  the  different  bones  can  be 
recognized  so  well,  in  fact,  that  the  study  of  the  trans- 
formation of  bone-tissue  is  no  longer  based  upon 
mere  conjecture. 

The  organic  tissues  of  the  human  body  show  per- 
meability of  a  medium  degree.  The  muscular  layer 
of  the  heart,  or  of  a  hand  or  foot  of  ordinary  size, 
has  a  permeability  about  the  same  as  that  of  a  liver 
or  kidney  of  the  same  thickness.  The  tissues  of  the 
nerves  and  the  blood-vessels  are  a  little  less  per- 
meable. This  explains  why  in  skiagraphs  of  the  soft 
parts  no  particular  variety  of  tissue,  as  of  muscle,  ten- 
don, ligament,  nerves,  or  vessels,  is  distinctly  marked. 
When  one  or  another  tissue  appears  more  distinct, 
this  fact  may  be  attributed  mainly  to  the  greater  thick- 
ness of  the  mass  of  the  tissue  in  question,  and  less  to 
its  own  character.  About  the  same  degree  of  perme- 
ability is  shown  by  hyaline  cartilage  and  by  normal 
blood  as  by  that  which  is  decomposed. 

In  a  good  skiagraph  all  kinds  of  metal  (bullet, 
needle,  nails),  stone,  wood,  and  glass  will  be  shown. 
The  weight  of  the  smallest  splinter  of  iron  so  far  dem- 


PRACTICAL    USE    OF    RONTGEN    RAYS.  287 

onstrated  was  0.0202  gm.  Calcified  trichinae  also 
show  easily. 

All  varieties  of  fractures  and  their  complications, 
callus  formations,  and  dislocations  are  representable. 

After  osteoplastic  resection  the  result  can  be  ascer- 
tained by  the  rays.  Months  after  osteoplastic  ampu- 
tation of  a  leg  the  author  was  able  to  demonstrate  the 
small  bone-fragments  which  were  bent  inward  from  the 
cortex  of  the  tibia  and  fibula  for  the  purpose  of  making 
a  solid  stump. 

The  differentiation  between  bony  and  fbrous  anky- 
losis is  now  as  easy  as  it  is  important.      (See  Fig.  1 19.) 

In  the  treatment  of  congenital  dislocation  of  the  hip 
the  skiagram  will  determine  what  method  of  treatment 
should  be  chosen,  as  it  reveals  well  the  relations  be- 
tween the  femur  and  the  acetabulum.  If  the  condition 
of  the  latter  be  unfavorable,  bloodless  reduction  will 
be  impossible,  and  a  cutting  operation  must  be  per- 
formed. The  skiagram  will  also  demonstrate  whether 
reduction  of  a  hip  dislocation  was  successful  or  not. 
It  is  true  that  after  perfect  reduction  the  head  of  the 
femur  can  be  felt  between  the  spina  and  the  symphysis 
in  the  majority  of  cases,  and  also  that  the  characteris- 
tic noise  can  be  perceived  while  the  head  is  jumping 
over  the  margin  of  the  acetabulum.  But,  on  the  other 
hand,  it  can  not  be  denied  that  the  noise  is  often  indis- 
tinct, and  that  the  thickness  of  the  muscles  oftentimes 
impairs  our  judgment,  so  that  it  is  the  skiagram  only 
which  gives  indisputable  information. 

In  the  various  forms  of  talipes  and  in  floating  bodies 
in  the  knee-joint  the  rays  are  also  serviceable. 

Rachitic  deformities  can  also  be  well  represented. 
Particularly  in  obstetrics,  the  study  of  a  rachitic  pelvis 
is  of  great  importance. 


288  APPENDIX. 

Differentiation  is  easily  made  between  the  osseous 
and  articular  changes  in  acromegaly  and  osteoarthro- 
pathie  hypertropliiante  pneumique. 

The  author  has  succeeded  in  obtaining  undeniable 
signs  of  fracture  of  the  coccyx  in  two  cases  of  alleged 
coccygodynia.  The  conclusion  is  obvious  that  in  most 
of  the  cases  which  were  taken  lor  coccygodynia,  and 
which  were  preceded  by  trauma,  a  fracture  or  infrac- 
tion had  Occurred. 

Inflammatory  processes — spondylitis,  for  instance — 
can  easily  be  differentiated  from  fractures  of  the  spinal 
column,  and  tubercular  foci  in  the  bones  can  also  be 
represented.  The  same  applies  to  osteomyelitis  (see 
Fig.  142)  and  necrosis. 

Iodoform- glycerin  injected  into  tubercular  joints  can 
be  recognized  as  a  distinct  shadow,  and  thus  may  some- 
times oqve  evidence  of  the  extent  of  fistulous  tracts. 

The  cartilages  of  joints  are  permeable  to  the  rays  ; 
but  if  they  atrophy  on  account  of  arthritic  processes, 
a  skiagram  of  the  same  appearance  as  that  of  ankylo- 
sis is  obtained.  The  interspace  always  found  between 
two  bones  of  a  joint  under  normal  conditions  has  then 
disappeared.  The  differentiation  between  diseased 
cartilage  and  ankylosis  is  easy,  as  in  the  last  event 
mobility  is  arrested. 

Deficiencies  of  the  skull,  especially  such  as  those 
caused  by  syphilis,  are  an  interesting  object  for  skiag- 
raphy. 

Differentiation  between  simple  arthritis,  rheumatism, 
and  tubercular  and  syphilitic  affections  of  the  joints  is 
also  possible. 

Foreign  bodies  in  the  skull  or  in  the  eye  are  easily 
reproduced. 


PRACTICAL  USE  OF  RONTGEN  RAYS.        289 

Solid  tumors,  such  as  osteomas,  osteochondromas, 
osteosarcomas,  enchondromas,  and  fibromas  are  also 
well  represented.  In  a  case  of  aneurysm  of  the  thigh, 
in  which  the  entire  absence  of  pulsation  was  a  per- 
plexing feature,  the  author  failed  to  get  any  posi- 
tive information  as  to  the  character  of  the  tumor. 
Still,  the  rays  were  found  to  be  of  great  value,  inas- 
much as  they  excluded  several  possibilities  in  the  case 
— viz.,  osteoma,  osteochondroma,  and  osteosarcoma — 
for  which  the  hard  immovable  growth  could  have  been 
mistaken.  But,  considering  that  in  the  event  of  the 
presence  of  a  growth  of  this  character  the  skiagraph 
would  not  have  shown  the  outlines  of  the  bone  normal 
and  distinct,  they  were  excluded.  In  aneurysm  of  the 
thigh  the  thick  femoral  muscles  of  course  veil  the  out- 
lines of  the  aneurysm-wall,  while  the  structure  and  out- 
lines of  the  bone  would  distinctly  show.:|: 

In  thoracic  surgery  skiagraphy  has  proved  that  after 
subperiosteal  resection  of  a  rib  the  exsected  portion  is 
always  more  or  less  re-formed. f 

The  extent  of  a  pyothoracic  cavity  can  be  repre- 
sented by  filling  it  with  iodoform-glycerin.  The  sub- 
nitrate  of  bismuth,  which  is  not  permeable  by  the  rays, 
furnishes  a  still  more  marked  contrast;  but  as  it  inter- 
feres with  the  treatment,  its  use  can  not  be  recom- 
mended by  the  author  for  this  special  purpose. 

Pleuritic  effusions  show  a  marked  opacity  through 
the  fluoroscope.     The  larger  the  amount  of  effusion, 

*  Compare  the  author's  article  on  the  difficulty  of  differentiating  be- 
tween femoral  aneurysm  and  osteosarcoma  in  "  International  Clinics," 
vol.  iv,  Ninth  Series. 

f  Compare  the  author's  article  on  "  Pyothorax,"  in  the  "  International 
Medical  Magazine,"  for  January,  1897. 
19 


29O  APPENDIX. 

the  greater  the  degree  of  opacity.  In  pyothorax  the 
opacity  is  somewhat  less  complete  than  in  serothorax. 
Especially  on  the  right  side,  the  outlines  of  the  liver 
show  a  marked  contrast  to  the  lower  boundary-line  of 
the  effusion.  The  upper  boundary-line  of  the  effusion 
generally  appears  convex,  but  if  the  patient  inspires 
deeply,  or  if  he  coughs  violently,  it  loses  its  convexity 
and  becomes  horizontal.  By  changing  the  position  of 
the  patient,  of  course,  displacements  of  the  effusion 
are  observed  accordingly.  Uniform  transparency  above 
the  effusion  points  to  the  result  of  a  simple  inflamma- 
tory process,  while  constant  opacities  of  an  irregular 
appearance  justify  a  suspicion  of  beginning  tuberculosis. 

As  a  rule,  it  is  found  that  the  area  of  dullness  corre- 
sponds to  the  area  of  the  shadow.  It  is  natural  that 
the  representation  of  calcareous  areas,  as  well  as  of 
cavities,  in  tuberculous  lungs  should  not  be  attended 
with  any  technical  difficulties.  Mediastinal  and  pul- 
monic tumors  which  on  percussion  did  not  show  any 
dull  area  pointing  to  their  presence  are  recognized. 
Swollen  bronchial  glands  have  also  been  diagnosti- 
cated by  the  rays.  Hypertrophied  pleurce  show  a 
very  distinct  shadow,  which  is  as  thick  as  liver-tissue. 
This  renders  exploratory  pleurotomy,  advised  by  the 
author, *  entirely  unnecessary. 

Hydropneunwthorax  may  also  be  recognized  by  the 
rays,  which  show  the  very  dark  outlines  of  the  exuda- 
tion in  contrast  to  the  lio-ht  shade  of  that  intrathoracic 
area  which  contains  air.  The  dark  boundary-line  of 
the  exudation  can  be  recognized  by  the  fluoroscope  as 
an  ascending  and  descending  line  during  expiration. 

*See  "Exploratory  Pleurotomy  and  Resection  of  Costal  Pleura," 
"  New  York  Medical  Journal,"  June  15,  1895. 


PRACTICAL    USE    OF    RONTGEN    RAYS.  29 1 

The  diagnosis  of  subphrenic  abscess,  formerly  so 
difficult,*  has  become  simple,  the  space  between  the 
diaphragm  and  the  lower  boundary-lines  of  the  abscess 
showing  distinctly.  If  situated  between  the  diaphragm 
and  the  liver,  the  image  is  particularly  distinct.*!* 

The  localization  of  lung-abscess  is  simplified  by  skia- 
graphing  in  different  positions. 

The  position,  size,  and  shape  of  the  Jieari  can  be 
elicited.  There  is  also  no  difficulty  in  differentiating 
aortic  aneurysm  from  mediastinal  tumor. 

Indeed,  as  to  type,  shape,  and  size  of  any  medias- 
tinal tumor,  much  more  reliable  information  can  be 
obtained  by  skiagraphy  than  by  percussion.  In  a  case 
of  aortic  aneurysm\  the  author  could  demonstrate  not 
only  complete  atrophy  of  the  sternum  down  to  the 
xiphoid  process,  and  of  the  sternal  portions  of  the 
clavicle,  but  also  the  overlapping  of  the  heart  over  the 
parasternal  line  and  the  downward  displacement  of  its 
apex.  The  oval  shape  of  the  heart  was  distinctly 
recognizable,  and  was  well  demarcated  from  the 
aneurysm,  the  enormous  intrathoracic  extent  of  which 
was  also  clearly  shown.  Another  skiagram  of  the 
same  case  showed  the  aortic  arch. 

The  patient  having  succumbed  to  pneumonia  six 
months  after  his  case  was  demonstrated,  the  author 
had  a  chance  to  verify  the  correctness  of  the  skiagrams 
by  the  autopsy. 

*  Compare  the  author's  article  on  "  Subphrenic  Abscess,"  "  Medical 
Record,"  February  15,  1896. 

+  Compare  the  author's  "  Beitrag  zur  Literatur  der  subphrenischen 
Abscesse,"  "  Langenbeck's  Archiv,"  vol.  lii,  No.  3  ;  and  "  The  Ront- 
gen  Rays  in  Surgery,"  "  International  Medical  Magazine,"  May,  1897. 

i  Compare  the  author's  article  on  "  An  Extraordinary  Case  of  Aortic 
Aneurysm,"  "  New  York  Medical  Journal,"  April  15,  1899. 


292  APPENDIX. 

If  we  realize  that  the  rays  enable  us  now  to  recog- 
nize aneurysms  at  their  earliest  stages,  it  becomes 
evident  that  frequently  a  series  of  prophylactic  meas- 
ures can  be  employed  which  may  counteract  any 
further  aneurysm-formation.  The  therapeusis  then 
being  under  perfect  control,  it  can  be  ascertained 
whether,  under  treatment,  either  improvement,  arrest, 
or  still  further  expansion  may  take  place. 

It  is  evident  that  in  all  these  cases,  especially  in 
accumulations  of  fluids,  the  question  of  displacement 
of  the  heart  is  of  great  importance  for  diagnosis. 

Bullets  in  the  thoracic  cavity  are  represented  with 
difficulty.  It  is  only  when  the  patient  possesses 
enough  energy  to  inspire  deeply  and  to  retain  breath 
for  half  a  minute  that  a  foreign  body  in  the  lungs  or 
pericardium  can  be  made  visible. 

The  diagnosis  of  arteriosclerosis,  while  very  easy  on 
the  surfaces  of  the  body,  was  very  difficult  in  the 
deeper  tissues.  According  to  the  text-books  on  in- 
ternal medicine,  the  thickening  of  the  tunica  intima 
can  not  be  recognized  if  it  be  confined  to  a  small 
area  or  to  single  small  foci.  It  hardly  need  be  em- 
phasized how  important  it  is  to  know  whether,  in  a 
given  case  of  sclerosis  of  the  radial  artery,  for  instance, 
there  exist  foci  in  other  vessels  besides.  Nor  can  it 
be  a  matter  of  indifference  what  the  number  of  these 
obstructive  foci  is,  and  whether  a  large  artery,  such  as 
the  aorta,  or  only  a  small  one,  such  as  the  temporalis,  is 
concerned.  The  presence  of  a  large  number  of  foci 
means  a  loss  of  propelling  energy  in  the  circulation, 
which  can  be  compensated  only  by  the  increased  work- 
ing power  of  the  left  ventricle.  The  arterial  pressure 
thus  becoming  higher,  hypertrophy  of  the  overworked 


PRACTICAL    USE    OF    RONTGEN    RAYS.  293 

ventricle  will  be  the  most  natural  consequence.  If  such 
foci  are  recognized  at  an  early  stage,  proper  prophyl- 
axis can  accomplish  a  great  deal  in  preventing  secon- 
dary disturbances.  The  prognostic  significance  of  an 
exact  knowledge  of  the  condition  of  the  arteries  is  also 
evident.  The  Ront^en  ravs  give  us  a  most  reliable 
method  of  ascertaining  the  condition  of  the  vessels,  and 
this  in  nearly  every  part  of  the  body.  In  a  case  of 
sclerosis  of  both  radial  arteries  the  author  studied  the 
forearm,  head,  neck,  and  femoral  and  aortic  regions 
skiagraphically.  Nowhere  did  the  conspicuously  de- 
veloped plates  show  any  indications  of  degeneration 
of  any  artery  except  on  the  forearm.  From  the  nega- 
tive state  of  the  other  skiagraphs  the  author  drew  the 
conclusion  that  the  patient's  arteriosclerosis  was  con- 
fined to  the  radialis  and  anterior  interossea — a  limita- 
tion which  harmonized  with  the  good  general  condition 
and  the  absence  of  palpitation,  dyspnea,  and  vertigo. * 

Enchondroma  of  the  larynx  can  be  easily  recog- 
nized. Aneurysm  of  the  carotid,  the  subclavian,  the 
anonyma,  and  the  abdominal  aorta  are  also  represent- 
able. 

In  abdominal  skiagraphy  great  progress  has  also 
been  mad  erecently.  Total  transposition  of  the  viscera 
could  be  well  represented  by  the  author.-j*  The  stom- 
ach, the  intestine,  and  the  bladder  are  of  equal  trans- 
lucency,  and  skiagraphs  of  these  organs  have  to  be 
taken  cum  prano  salis.  The  much  more  solid  masses 
of  the  liver,  the  spleen,  and  the  kidneys  can  be  well 
represented. 

In  a  case  of  carcinoma  of  the  pylorus  in  which  the 

*  Compare  the  "  New  York  Medical  Journal,"  January  22,  1898. 
f"  Annals  of  Surgery,"  May,  1899. 


294  APPENDIX. 

author  performed  a  successful  pylorectomy,  a  distinct 
shade  had  been  obtained. 

To  make  the  outlines  of  the  stomach  visible,  the 
stomach  may  be  filled  with  salts  which  are  imperme- 
able to  the  rays — subnitrate  of  bismuth,  for  instance. 
The  author,  however,  prefers  the  introduction  of  a  soft 
rubber  tube  the  lumen  of  which  is  filled  with  mercury. 
Of  course,  in  a  tube  of  this  kind  an  eye  must  not  be 
cut  out.  A  rubber  tube  containing  thin,  flexible  steel 
wire  in  spiral  form,  advised  by  the  author,*  permits  of 
rapid  representation  of  the  outlines  of  the  stomach. 
The  stoppage  of  this  tube  indicates  its  arrival  at  the 
large  curvature  of  the  stomach,  and  further  propulsion 
shifts  it  alongside  its  wall.  There  the  steel  spiral  is 
easily  shown  by  the  skiagraph.  In  carcinoma  of  the 
esophagus  the  author  has  tried  the  same  experiment 
with  smaller  sounds,  but,  unfortunately,  few  patients 
are  able  to  tolerate  them  for  a  length  of  time  sufficient 
for  good  representation. 

Hydronephrosis  and  echiuococcus  were  reported  as 
being  recognized  in  connection  with  the  usual  diagnos- 
tic methods. 

Renal  and  vesical  calculi  may  also  be  skiagraphed. 
In  the  living  subject,  with  the  old  vacuum  tubes  only 
such  calculi  could  be  represented  as  consisted  of  a 
hard  and  firm  layer,  like  the  oxalates,  while  the  more 
penetrable  urates  left  an  indistinct  shadow,  and  the 
translucent  phosphates  hardly  showed  at  all.  The 
success  of  skiagraphy  in  calculi  of  the  urinary  tract 
depended  only  upon  the  different  chemic  composition 
of  the  calculi,  and  consequently  upon  their  greater  or 

*  See  "The  Rontgen  Rays  in  Surgery,"  "International  Medical 
Magazine,"  May,  1897. 


PRACTICAL    USE    OF    RONTGEN    RAYS.  295 

less  opacity.*  Now,  with  the  new  quick-penetrating 
tubes,  more  or  less  opaque  shadows  of  all  three  dif- 
ferent varieties  can  be  obtained. 

Gall-stones  could  not  be  skiagraphed  until  recently. 
It  was  the  privilege  of  the  author  to  show  the  first  un- 
disputed skiagraph  of  gall-stones  in  the  living  subject 
at  the  October  meeting  of  the  New  York  County 
Medical  Association,  in  1899.  Gocht,  Oberst,  Rumpf, 
Dumstrey,  and  Metzger,  who  are  among  the  best-known 
experts  in  skiagraphy,  declared  recently  that  biliary 
calculi  could  not  be  represented.  The  last-named  is 
even  responsible  for  the  bold  assertion  that  "  nowa- 
days nobody  will  any  longer  maintain  that  gall-stones 
can  be  skiagraphed";  that  "all  experiments  in  this 
direction  have  proved  to  be  failures";  and  that  "it 
appears  hopeless  that  such  experiments  will  give  any 
other  result  in  the  future."     But  errare  humanum  est ! 

After  many  trying  disappointments  the  author  suc- 
ceeded for  the  first  time  in  skiagraphing  the  chole- 
lithiasis of  a  woman  seventy-two  years  of  age,  after  hav- 
ing employed  four  different  photographic  plates  at  the 
same  time.  The  upper  plate,  situated  directly  below 
the  region  of  the  orall-bladder,  showed  the  outlines  of 
the  liver  well,  while  in  the  fourth  and  remotest  plate 
it  appeared  only  faintly  ;  but  the  calculi  were  clearly 
represented.  The  next  exposure  was  made  with  a 
quick-penetrating  focus-tube  on  a  single  plate,  and 
lasted  ten  minutes.  After  it  was  found  how  long  it 
took  with  this  tube  to  represent  the  liver  and  the  os 
ilii,    a    second    plate    was    exposed,    this   time   for   six 

*  Compare  the  author's  previous  publications  on  this  subject  :  "  Inter- 
national Medical  Magazine,"  May,  1897  ;  and  "American  Journal  of 
Cutaneous  and  Genito-urinary  Diseases,"  January,  1899. 


296  APPENDIX. 

minutes  only.  This  second  skiagraph  showed  the 
denser  tissues  less  clearly,  while  the  calculi  were 
much  more  distinct.  An  exposure  lasting  seven 
minutes,  one  for  eight  minutes,  and  one  for  nine 
minutes  were  also  made,  all  showing-  that  the  longer 
the  time  of  exposure,  the  clearer  the  denser  tissues 
and  the  obscurer  the  calculi  appeared.  It  thus  became 
evident  that  one  exposure  is  not  sufficient  to  determine 
the  length  of  time  required  by  each  individual  tube  for 
the  representation  of  each  individual  gall-stone  type. 
A  test  should  therefore  be  made  first  by  making  a 
short  as  well  as  a  long  exposure  in  a  case  of  suspected 
cholelithiasis  ;  that  is,  an  exposure  of  about  four  min- 
utes as  well  as  one  of  nine  or  ten.  The  most  powerful 
focus-tubes  at  present  attainable  should  be  chosen  for 
the  purpose.  By  comparing  the  results  the  proper 
time  of  exposure  for  the  best  results  can  be  estimated. 
For  better  identification  the  contours  of  the  organs, 
especially  the  liver,  should  be  outlined  by  thin  wire  at- 
tached to  the  plate  before  the  final  skiagram  is  taken. 
The  results,  of  course,  are  to  some  extent  dependent 
upon  the  chemic  composition  of  the  bilia7y  calculi,  which 
is  far  more  complex  than  that  of  calculi  in  the  urinary 
tract.  All  the  different  types  of  calculus  were  skia- 
graphed  by  the  author  on  a  photographic  plate,  in 
order  to  obtain  a  visual  comparison  of  their  perme- 
ability. The  same  calculi  were  then  irradiated  through 
the  living  body,  thus  practically  demonstrating  the  dif- 
ference in  translucency.  The  common  biliary  calculi, 
the  most  frequent  type,  were  found  permeable  to  the 
rays,  and  therefore  produced  a  light  shade  only.  If 
present  in  large  numbers,  the  shade  was  somewhat 
more  conspicuous.      Calculi  composed  of  pure  choles- 


PRACTICAL    USE    OF    RONTGEN    RAYS.  297 

terin  are  less  permeable  to  the  rays  than  the  common 
type,  and  show  a  slightly  more  distinct  shade. 

The  stratified  cholesterin  calculi,  on  account  of  their 
admixture  of  calcium,  show  much  less  permeability  to 
the  rays,  wherefore  a  distinct  skiagraph  can  be  counted 
upon. 

The  mixed  bilirubin  calculi,  which,  besides  bilirubin- 
calcium,  contain  traces  of  copper  and  iron,  are  less 
permeable  to  the  rays  than  all  the  former  varieties, 
and  consequently  give  a  very  distinct  shade.  The 
same  applies  to  the  pure  bilirubin-calcium  calculi. 

In  skiagraphing  the  gall-bladder  it  is  necessary 
that  the  patient  should  lie  on  his  abdomen  with  a 
pillow  underneath  his  symphysis  as  well  as  under- 
neath his  clavicle.  The  elevation  produced  by  these 
pillows  permits  the  protrusion  of  the  region  of  the 
gall-bladder,  thus  bringing  the  calculi  nearer  to  the 
photographic  plate.  The  approximation  is  increased 
by  turning  the  body  slightly  to  the  right  and  raising 
the  left  side. 

Another  point  of  importance  is  that  the  rays  should 
not  penetrate  the  abdomen  in  a  vertical  direction,  but 
from  the  side,  so  that  the  thick  and  less  transparent 
tissue  of  the  liver  is  not  permeated  in  its  whole  diam- 
eter. The  direction  of  the  rays  should  be  such  that 
they  form  an  angle  of  about  sixty  degrees  with  the 
plate.  The  tube  must  be  as  near  the  abdomen  as 
possible. 

By  employing  this  method,  not  only  the  size,  shape, 
and  diameter  of  the  gall-stones  can  be  determined, 
but  they  can  also  be  localized.  How  important  it  is  to 
know  whether  there  are  also  calculi  in  the  liver  besides 
those  present  in  the  gall-bladder!      Calculi  in  the  com- 


298  APPENDIX. 

mon  duct  can  also  be  shown,  while  formerly  it  was 
only  after  extensive  exposure  by  laparotomy  that  such 
diagnosis  could  be  made  with  any  degree  of  certainty. 
Exploratory  laparotomy  for  suspected  cholelithiasis 
will  hardly  be  necessary  any  more. 

If  medical  treatment  of  cholelithiasis  is  tried  on  the 
basis  of  a  skiagraph,  it  can  be  ascertained  by  subse- 
quent exposures  whether  any  calculi  were  dislodged  or 
whether  some  had  escaped  into  the  duodenum.  The 
same  applies  to  the  state  of  the  intrahepatic  calculi. 
If  the  calculi  prove  to  be  of  very  large  size,  their  re- 
moval by  medical  treatment  can  naturally  not  be  ex- 
pected. 

Since  his  latest  publication  *  the  author  has  had  fre- 
quent opportunities  to  skiagraph  biliary  calculi,  and 
with  the  improvement  in  the  routine,  the  skiagrams 
became  much  clearer.  In  a  case  of  cholelithiasis 
in  which  cholecystotomy  was  performed  by  the 
author,  pure  cholesterin  calculi  were  found,  which,  in 
spite  of  their  transparency,  had  made  a  well-defined 
shadow  on  the  plate  before  operation  was  resorted 
to. 

The  question  whether  or  not  an  operation  should  be 
performed  in  cholelithiasis  can  thus  be  definitely  set- 
tled by  the  Rontgen  rays.  When  small  stones  are 
represented,  there  is  a  chance  for  medical  treatment. 
When  stones  are  found  too  large  to  pass  the  common 
duct,  medical  treatment  can  only  be  of  a  palliative 
character,  and  cholecystotomy  should  be  performed  as 
soon  as  the  calculi  prove  to  be  a  source  of  irritation. 

As  previously  mentioned,  an    excellent  tube  is  the 

* "  On  the  Detection  of  Calculi  in  the  Liver  and  Gall-bladder," 
"  New  York  Medical  Journal,"  January  20,  1900. 


PRACTICAL    USE    OF    RONTGEN    RAYS.  299 

conditio  sine  qua  non  for  skiagraphic  success  in  such 
delicate  work.  But  even  the  best  tubes  differ  in  their 
qualities,  and  must,  therefore,  be  studied  and,  so  to 
say,  individualized,  as  different  patients  are  to  be 
judged  differently,  although  suffering  from  the  same 
disease.  Absolute  laws  can  therefore  not  be  made. 
(Compare  p.  305.)  In  general,  it  may  be  said  that  the 
more  translucent  a  calculus,  the  shorter  must  be  the 
exposure  ;  therefore  the  pure  cholesterin  calculus  re- 
quires a  shorter  exposure  than  one  containing  calcium. 
But  the  great  trouble  is  that  when  skiagraphing  for 
suspected  calculi,  we  do  not  know  beforehand  what 
may  be  the  chemic  composition  of  the  alleged  stones, 
and  therefore  we  do  not  know  what  time  of  exposure 
will  be  the  most  desirable.  This  difficulty  can  be 
overcome  to  some  extent  by  making  a  minimum  and 
a  maximum  exposure  at  the  same  time.  If  a  short  ex- 
posure reveals  the  presence  of  calculi,  while  a  long 
exposure,  made  at  the  same  time,  is  negative,  the  prob- 
ability is  that  a  translucent  calculus  (cholesterin)  is 
present.  If  a  short  exposure  proves  to  be  positive  and 
a  small  one  negative,  a  dense  calculus  may  be  inferred. 

Even  a  poor  negative,  if  it  shows  nothing  but  the 
faint  outlines  of  elliptic  and  faceted  bodies  in  the  re- 
gion of  the  ofall-bladder,  is  authoritative.  Sometimes 
the  negative  shows  nothing  but  the  calculi.  They 
must  always  be  most  carefully  studied,  because  the  in- 
experienced eye  often  will  not  recognize  the  calculi, 
which  are  evident  to  the  trained  eye  at  a  glance. 

All  authors  agree  that  one  of  the  greatest  difficul- 
ties encountered  in  the  treatment  of  spina  bifida  has 
been  the  fact  that  its  various  types — viz.,  simple  menin- 
gocele, myelomeningocele,  and  myelocystocele — could 


2,00  APPENDIX. 

not  be  differentiated.  Especially,  the  distinction  be- 
tween meningocele  and  myelocystocele  has  been  gener- 
ally impossible.  Considering  only  the  one  point  that  in 
meningocele  aspiration  should  be  tried  first,  while  in 
the  other  varieties  extirpation  must  be  resorted  to,  the 
importance  of  the  question  is  self-evident.  The  skia- 
gram now  shows  with  absolute  distinctness  whether  or 
not  there  is  an  opening  in  the  spinal  column  ;  it  shows 
also  the  presence  or  absence  of  the  nerve-substance, 
and  sometimes  even  its  expansion  in  the  sac.  In  those 
rare  cases  in  which  the  presence  of  lipoma  or  fibro- 
myoma  is  in  question  it  is  again  the  skiagram  which 
gives  the  needed  information.* 

Soon  after  the  utilization  of  Rontgen's  discovery, 
reports  of  extensive  dermatitis  and  gangrene  of  the 
integument  were  published,  which  disturbed  the  public 
mind  in  a  deplorable  and  unjustifiable  manner.  But, 
especially  since  the  time  of  exposure  is  now  so  much 
shorter  than  during  the  earlier  stages  of  the  art,  the 
possibility  of  originating  skin  irritation  is  extremely 
small. 

It  is  undeniable  that  a  peculiar  trophoneurotic  idio- 
syncrasy may  exist  in  some  individuals,  but  in  the 
great  majority  of  known  cases  the  burns  of  the  skin 
were  caused  either  by  the  ignorance  of  the  unskilful 
operator,  the  tube  often  being  too  near  the  object,  or 
by  too  prolonged  and  too  often  repeated  exposures.  It 
is  not  surprising  to  observe  such  accidents  so  long  as 
laymen,  such  as  opticians  and  instrument-makers,  who 
understand   nothing  of  the   anatomy  and   physiology 

*  Compare  the  author's  article  on  "  The  Rontgen  Rays  in  Spina  Bif- 
ida," "  Medical  Record,"  August  13,  1898. 


PRACTICAL  USE  OF  RONTGEN  RAYS.        3OI 

of  the  skin,  are  intrusted  with  "the  manufacture  of 
skiagrams." 

As  in  many  other  respects,  the  question  of  proper 
dosage  must  also  here  be  perfectly  understood  by  the 
operator.  A  person  who  irradiates  a  patient  suffering 
from  sycosis  every  day  intensely  for  a  whole  hour, 
irrespective  of  the  reaction  following  such  a  radical 
procedure,  so  that  gangrene  occurs,  has  just  as  little 
business  to  do  skiagraphic  work  as  a  shoemaker  has 
to  prescribe  morphin. 

Since  February,  1896,  the  author  has  made  nearly 
three  thousand  skiagraphs,  and  has  never  observed 
the  slightest  irritation  of  the  skin  in  any  case  in  which 
the  rays  were  used  for  diagnostic  purposes.  In  two 
cases  only  was  circumscribed  depilation  observed.  In 
both  patients  the  skull  had  to  be  skiagraphed  fre- 
quently and  at  short  intervals  (one  was  the  case  illus- 
trated by  Fig.  161,  and  the  other  that  shown  in  Fig. 
172).  In  the  first  case  depilation  began  after  the  fifth, 
and  in  the  second  case  after  the  sixth,  exposure.  In 
both  instances  the  hair  was  perfectly  restored  three 
weeks  afterward. 

Changes  in  the  pigmentation  of  the  integument  or 
in  the  growth  of  the  finger-nails,  congestion,  inflam- 
mation, and  necrosis  of  the  skin  are  reported.  Some 
operators  have  observed  cessation  of  perspiration  on 
the  dorsum  of  their  hands.  The  source  of  such 
tissue-changes  is  like  that  of  other  burns  produced  by 
electricity. 

It  was  not  more  than  natural  that  these  properties 
of  the  rays  were  soon  utilized  for  tJierapeutic  pur- 
poses. Cases  of  hypertrichosis,  of  ncevus  vasculosis, 
of  all  the  various  types  of  eczema,  psoriasis,  and  syco- 


102  APPENDIX. 


sis,  have  been  reported  as  cured  by  the  rays.  There 
can  also  be  no  doubt  that  parasitic  skin-diseases,  such 
as  lupus  vulgaris  and  erythematosis,  yield  to  the  rays. 
Sycosis  parasitica  as  well  as  non-par asitica  and  favus 
have  been  cured  after  one  exposure. 

In  a  case  of  sycosis  parasitica  which  had  existed  for 
six  years,  and  had  resisted  the  usual  methods  of  treat- 
ment, the  author  observed  a  perfect  cure  after  an 
exposure  which  lasted  seven  minutes  only. 

In  a  case  of  lupus  of  the  inguinal  region  the  author 
observed  a  perfect  result.  After  the  sixth  exposure 
inflammation  of  the  lupous  area  began,  and  the  nodules 
shelled  out,  so  to  say,  together  with  the  destroyed  tis- 
sue. In  their  place  a  light  red  ulcus  remained,  which 
bled  on  the  slightest  touch,  and  which  did  not  cicatrize 
until  nine  months  after  the  last  exposure.  In  such 
cases  transplantation  is  generally  indicated.  It  goes 
without  saying  that  this  mode  of  treatment,  while  most 
effective,  is  very  annoying  to  the  patient,  whose  grati- 
tude to  the  physician  is  somewhat  restricted  on  that 
account,  even  after  perfect  recovery. 

In  some  of  the  cases  reported  the  nodules  did  not 
shell  out,  but  shrunk,  presenting  the  appearance  of 
having  been  painted  with  varnish. 

A  great  deal  can,  however,  be  done  to  limit  the  ill 
consequences  of  the  irradiation  treatment  of  skin  dis- 
eases, which  should  not  be  resorted  to  unless  all  other 
therapeutic  measures  have  been  exhausted.  Under 
proper  precautions  the  ill  effects  of  the  rays  can  be 
avoided.  In  the  first  place,  the  healthy  parts  in  the 
vicinity  of  the  diseased  area  should  be  protected  by 
sheets  of  staniol.  Then  the  patient's  subjective  condi- 
tion should  be  carefully  watched.     As  soon  as  there  is 


PRACTICAL    USE    OF    RONTGEN    RAYS. 


j^j 


a  slight   bu rnino-  sensation  or  itching  within   the  irra- 
diated  sphere,  further  exposures  must  be  stopped. 

For  therapeutic  purposes  the  tube  should  be  as  near 
to  the  diseased  area  as  possible,  and  the  time  of  the 
first  exposure  should  not  be  longer  than  ten  minutes. 
Later  on,  when  no  reaction  shows,  the  irradiation  may 
be  kept  up  for  from  twenty  to  thirty  minutes.  In 
lupus  as  many  as  fifty  exposures  may  be  necessary 
until  the  nodules  are  destroyed.  In  obstinate  cases 
exposures  may  be  made  daily. 

During  the  intervals  the  diseased  area  should  be 
powdered  with  amylum  or  dermatol.  In  the  event  of 
relapse,  the  same  treatment  must  be  commenced 
again. 

It  is  necessary  to  individualize  just  the  same  as  in 
other  therapeutic  indications.  Some  individuals  show 
signs  of  irritation  after  a  few  exposures,  and  others  do 
not  react  until  after  frequently  repeated  and  intense 
irradiations. 

At  first  these  remarkable  results  were  explained  on 
the  theory  of  bactericidal  influence  of  the  rays.  But  it 
seems  that  their  effect  is  of  a  decidedly  electrochemic 
character,  the  congestion  caused  by  the  irradiation 
being  mainly  responsible,  just  like  the  artificial  hyper- 
emia in  tuberculosis.  In  disturbed  nutrition  of  the 
skin  the  inflammatory  reaction  produced  by  the  rays 
would  set  up  an  alteration  in  the  circulation  of  the 
affected  spheres. 

Bacteriologic  experiments  have  shown  that  the  rays, 
applied  directly  after  inoculation  with  anthrax  bacilli, 
as  well  as  with  streptococci  and  staphylococci,  had  no 
effect.  But  pure  cultures  of  cholera,  typhus,  and  diph- 
theria died  after  forty-eight  minutes'  exposure  to  in- 


304  APPENDIX. 

tense  irradiation.  It  seems  that  various  bacteria  react 
differently  according  to  the  quality  of  the  plasma  and 
the  degree  of  the  fluid  they  contain. 

Dentistry  has  also  profited  considerably  by  the  rays. 
The  relation  of  the  dental  roots  and  their  position, 
the  presence  or  absence  of  the  milk-teeth  as  well  as 
of  the  permanent  teeth  in  children,  or  of  an  old  root, 
and  foreign  bodies  (fillings,  pieces  of  chisel  broken  off, 
for  instance,  while  excavating  a  carious  tooth)  can  be 
clearly  demonstrated. 

Sometimes  it  is  of  great  forensic  importance  to  de- 
termine the  age  of  an  infantile  corpse  by  skiagraphing 
the  teeth. 

As  a  rule,  it  will  suffice  to  place  the  face  portion 
nearest  to  the  tooth  in  question  on  an  ordinary  Ront- 
gen  plate.  If  fine  details  are  demanded,  flexible  films 
may  be  introduced  into  the  oral  cavity,  where  they  will 
adapt  themselves  to  the  contours  of  the  maxilla. 

It  has  been  reported  that  certain  types  of  neuralgia 
are  benefited  by  long  exposures. 

As  stated  before,  the  intensity  of  the  rays  increases 
in  proportion  to  the  height  of  the  vacuum.  If  very  high 
vacua  are  used,  even  the  bones  of  the  hand  may  be- 
come so  translucent  that  they  can  hardly  be  distin- 
guished on  the  plate.  Thus  it  will  be  easily  under- 
stood why,  for  the  representation  of  the  bones  of  the 
hand,  a  tube  with  a  low  vacuum  (so-called  mild  or  soft 
tube)  is  to  be  chosen,  while  if  the  rays  have  to  per- 
meate a  very  thick  body,  such,  for  instance,  as  the 
pelvis  of  a  fat  person,  it  is  the  high  vacuum  tube 
(hard  tube)  only  that  would  be  capable  of  throwing 
so   much   light  through  it  as   to    show  a  well-defined 


PRACTICAL    USE    OF    RONTGEX    RAYS.  305 

shade  on  the  plate.  From  this  we  learn  that,  accord- 
ing to  the  thickness  and  permeability  of  the  object  to 
be  skiagraphed,  tubes  of  low,  high,  and  very  high 
vacuum  must  be  at  hand. 

Recently,  tubes  have  been  constructed  by  Gunde- 
lach  which  permit  of  regulation  by  the  diffusion  of 
hydrogen.  Into  the  wall  of  a  tube  of  this  kind 
a  small  platinum  wire  is  fused,  the  end  of  which 
protrudes  outside  to  the  extent  of  two  inches.  If  this 
protruding  piece  of  platinum  is  heated  by  a  Bunsen 
burner,  the  hydrogen  of  the  flame  diffuses  into  the 
interior  of  the  tube,  thus  auomientinof  the  intratubal 
vacuum  at  will.  The  heating  process  must  be  kept  up 
from  one-half  to  three  minutes.  The  handling  of  these 
tubes  is  troublesome,  but  their  usefulness  is  great. 

Another  most  important  factor  that  affects  the  dis- 
tinctness of  a  skiagraph  is  the  length  of  time  of  tJie 
exposure.  If  the  most  perfect  apparatus  is  used,  the 
hand  of  an  adult  can  be  well  represented  in  less  than 
half  a  minute,  while  the  forearm  requires  one  minute 
and  a  half.  The  elbow,  humerus,  and  foot,  at  an 
average,  need  from  two  to  two  and  one-half  minutes, 
and  the  lee,  knee,  and  thorax,  from  three  to  four 
minutes  ;  while  for  the  shoulder  and  thigh  from  four 
to  five,  for  the  skull  from  five  to  six,  and  for  the  pelvis 
from  six  to  ten,  minutes  are  generally  necessary. 

The  capacity  of  a  tube  is  tried  best  by  using  it  for 
different  lengths  of  time — viz.,  for  twenty,  lorty,  or 
sixty  seconds — on  the  same  subject,  and  determining 
its  penetrating  power  by  comparison  of  the  skiagraphs. 
In  children  the  time  of  exposure  must  be  lessened,  in 
view  of  the  greater  translucency  of  the  bones. 

The  distance  of  the  plate  from  the  tube  also  deserves 


306  APPENDIX. 

great  attention.  Different  distances  give  different  re- 
lations, and  the  less  the  distance  between  plate  and 
tube,  the  larger  the  silhouette  of  the  body  ;  but  the 
smaller  the  silhouette,  the  more  correct  the  anatomic 
proportion  of  the  tissues.  The  more  distant  the  tube 
is  placed,  the  longer  the  time  of  exposure  must  last. 
On  an  average,  an  equally  good  skiagraph  of  the  hand 
is  produced  when  the  distance  is  six  inches  and  when 
the  exposure  has  lasted  half  a  minute,  as  when  the 
distance  was  twelve  inches  and  the  exposure  a  whole 
minute. 

For  locating  foreign  bodies,  apparatus  have  been 
devised  by  Hoffmann,  Levy-Dorn,  Sehrwald,  and 
Angerer.  The  author  has  thus  far  been  able  to  locate 
foreign  bodies  in  the  simple  manner  described  on  page 
265.  The  wire  letters  used  for  registration  (p.  311) 
can  also  be  used  as  landmarks  ;  one,  for  example, 
being  placed  above  the  plate  below  the  wound  or  scar 
signifying  the  entrance  of  the  foreign  body,  and  others 
at  proper  intervals  on  the  plate  as  well  as  on  the  sur- 
face of  the  limb.  For  localization  on  the  skull,  wire- 
may  be  wound  around  the  head,  and  at  various  inter- 
vals ciphers  (compare  p.  265)  may  be  spread  as  land- 
marks. The  same  means  may  be  employed  on  an 
extremity,  where  wires  may  be  wound  around,  and 
ciphers  put  on  the  limb  as  well  as  on  the  plate.  The 
same  principles  apply  to  other  parts  of  the  body  in 
proper  modification. 

The  objects  to  be  skiagraphed  must  be  in  close  con- 
tact with  the  photographic  plate.  As  far  as  their  posi- 
tion is  concerned,  it  is  advisable  to  take  the  forearm 
in  supination,  although  this  position  is  by  no  means 
the  most  comfortable  one  for  the  patient.     The  upper 


PRACTICAL    USE    OF    RONTGEN    RAYS.  307 

arm  and  the  thigh  can  be  taken  in  any  position.  The 
leg  should  be  skiagraphed  while  its  external  surface 
rests  on  its  support,  the  knee  being  bent  and  the  thigh 
rotated.  The  foot,  from  the  toes  up  to  the  upper  third 
of  the  metatarsus,  is  best  photographed  in  the  direction 
of  the  dorsum  toward  the  planta  pedis.  Further  back 
the  first  and  third  cuneiform  bones  and  the  scaphoid 
present  an  obstacle,  so  that  it  is  advisable  to  illuminate 
the  foot  on  these  portions  transversely  by  having  the 
outer  surface  rest  on  the  plate.  By  this  procedure  the 
isolated  shadows  of  the  astragalus,  the  calcaneum,  the 
os  cuboideum,  the  scaphoid,  and  the  fourth  and  fifth 
metatarsal  bones  can  be  seen.  The  hand  is  taken 
from  the  dorsum  through  to  the  palm.  The  knee-joint 
rests  preferably  on  the  external  condyle.  The  humero- 
ulnar  joint  should  be  taken  transversely,  while  the 
Jnunero-radial  joint  had  better  be  illuminated  from  the 
flexor  to  the  extensor  side.  The  hip-joint  is  taken 
best  by  turning  the  patient  from  his  recumbent  posi- 
tion inwardly,  so  that  the  anterior  axis  of  the  thigh 
forms  an  angle  of  from  thirty  to  forty  degrees  to  the 
underlying  plate.  The  opposite  hip  is  elevated  and 
supported  accordingly. 

With  respect  to  the  position  of  the  tube,  care  should 
be  taken  to  have  the  center  of  the  platinum  disc  exactly 
above  the  center  of  the  plate  upon  which  the  object 
rests. 

In  order  to  judge  a  skiagraph  thoroughly,  the  source 
of  the  current  (whether  battery  or  street),  the  length 
of  the  spark  of  the  induction  coil  (whether  a  vibrator  or 
an  air-blast  is  used),  the  intensity  of  the  tube,  the  dis- 
tance of  the  platinum  disc  of  the  tube  from  the  photo- 
graphic plate,   the  position   of  the  object,  the  sort  of 


308  APPENDIX. 

plate    used,   and    the   time   of   exposure,  must  all    be 
mentioned. 

For  examination  with  the  ftuoroscopc  a  room  must  be 
chosen  that  can  be  darkened  at  will,  but  the  photo- 
graphic work  can  be  done  in  any  room.  The  hand 
and  arm  can  be  photographed  on  a  table  while  the 
patient  is  seated  on  a  chair.  The  other  parts  of  the 
body  may  be  taken  while  the  patient  lies  either  on  a 
heavy  wooden    table    or    on    a  carpeted    floor.      (See 

Fig-  17 3-) 

Absolute  rest  is  the  conditio  sine  qua  non  of  a  dis- 
tinct picture.  In  children  and  in  nervous  adults  efforts 
to  attain  perfect  immobilization  may  fail.  The  trunk 
must  be  supported  properly  by  pillows,  while  an  ex- 
tremity can  be  kept  quiet  by  supporting  it  with  sand- 
bags. The  patient  should,  of  course,  be  placed  as 
comfortably  as  possible,  but  in  some  individuals  it  is 
utterly  impossible  to  take  a  skiagraph.  Infants  should 
be  lulled  into  sleep,  the  noise  of  the  battery,  if  not  too 
strong,  sometimes  acting  like  a  lullaby.  Anesthesia  for 
the  purpose  of  keeping  the  patient  quiet  should  be 
resorted  to  only  under  the  most  pressing  circum- 
stances. 

To  sum  up,  it  may  be  said  that  the  modus  operandi 
in  skiagraphy  would  be  about  the  following: 

If  the  thigh,  for  instance,  should  be  photographed 
(see  Fig.  173),  the  patient  is  laid  straight  down  on  the 
floor.  The  limb  must  be  denuded  and  placed  on  the 
top  of  a  sensitized  plate.  The  patient  is  told  to  be 
absolutely  quiet,  for  otherwise  the  whole  process  is 
spoiled.  The  tube  must  be  placed  above,  in  a  hori- 
zontal position,  where  it  is  held  by  an  adjustable 
stand.     The   stand  used  by  the   author   (Fig.    173,  s) 


PRACTICAL    USE    OF    RONTGEN    RAYS.  3OQ 

permits  of  a  wide  range  of  adjustment  in  the  lateral, 
vertical,  and  horizontal  directions,  so  that  the  object 
can  be  irradiated  from  all  sides.  Its  exact  position 
may  be  verified  by  dropping  a  plumb-line  from  above. 
Now  the  positive  wire  of  the  coil  is  connected  with 
the  wire-holder  of  the  inclined  platinum  disc  of  the 
tube,  while  the  negative  wire  is  attached  to  that  of 
the  concave  aluminium  pole.  If  the  lever  for  the  direct 
current  (Fig.  i  73,  I)  is  then  turned,  the  motor  begins  to 
run.  Thereafter  the  handle  (Fig.  173,  h)  of  the  switch 
of  the  coil  is  turned,  and  now  a  slight  spark  will  pass 
between  the  anode  (a)  and  the  cathode  (c).  By  man- 
ipulating the  rheostat  (r)  the  spark  is  increased  gradu- 
ally until  an  apple-green  light  fills  the  tube,  a  slightly 
dark  shadow  only  being  noticed  below  the  platinum 
disc.  With  the  aid  of  the  fluoroscope  or  of  the  skia- 
meter, it  can  be  now  ascertained  whether  the  fluor- 
escence is  intense  enough  for  thorough  penetration. 
The  fluoroscope  also  gives  a  rough  impression  of  the 
pathologic  conditions. 

If  all  works  well,  the  upper  surface  of  the  platinum 
disc  shows  a  gray  glow,  while  the  lower  surface 
produces  a  light  redness.  A  white-red  platinum  disc 
indicates  too  powerful  a  current ;  but  this  can  be 
diminished  by  turning  the  rheostat  backward.  If,  in 
such  an  event,  the  walls  of  the  tube  also  become  very 
hot,  it  is  advisable  to  stop  the  current  entirely  for 
at  least  half  a  minute.      (Compare  p.  281.) 

The  wires  leading  from  the  induction  coil  to  the  tube 
must  be  kept  separated  from  one  another  in  order  to 
avoid  shocks.  When  the  exposure  is  finished,  the 
levers  are  turned  back  in  the  same  succession. 

If  a  static    machine  is  used,  the  sliding  pole-pieces 


3io 


APPENDIX. 


are  separated  about  eight  inches,  the  large  balls  un- 
screwed from  the  pole-ends,  and  the  Leyden  jars  re- 
moved. The  condensers  must  then  be  screwed  on, 
and  the   square  platinum  disc  is  attached  to  the  posi- 


Fig.  174. — Complete  comminuted  intra-articular  fracture  of  the  lower  end  of 
the  radius  in  a  woman  of  forty  years,  showing  lateral  as  well  as  median  dis- 
placement of  fragments  (one  week  after  the  injury).  The  negatives  of  the  wire 
numbers  193  register  the  plate. 


tive  pole  of  the  condenser.  The  length  of  the  spark- 
gap  should  be  regulated  so  as  to  suit  the  vacuum: 
it  must  be  lone  if  the  tube  has  a  low  vacuum,  and  be 
short  if  it  has  a  hio-h  one.  The  machine  must  be  run 
rapidly,  but  never  backward  or  with  wrong  poles. 


PRACTICAL    USE    OF    RONTGEN    RAYS.  3 1  I 

The  plates  are  then  put  into  a  dark  place  until  they 
are  developed,  which  is  done  in  the  usual  way,  the 
very  simple  directions  being  obtained  with  the  plates 
when  purchased.  The  plates  should  be  labeled.  The 
author  uses  small  letters  and  numbers  made  of  copper 
wire  (Fig.  1 74),  which,  being  placed  on  an  edge  of 
the  plate,  mark  the  skiagram  properly  and  perma- 
nently, their  shades  appearing  on  the  plate.  If  the 
letter  L  is  put  at  the  left  and  R  at  the  right  margin 
of  the  plate  (Fig.  175),  the  correct  position  becomes 
evident  at  a  glance. 

Almost  all  the  illustrations  in  this  book  were  skia- 
graphed  on  Carbutt  X-ray  plates  ;  but  the  Cramer  and 
Schleussner  plates  also  give  very  good  results.  The 
latter  are  especially  to  be  recommended  for  rapid 
exposures. 

If  several  exposures  of  the  same  object  must  be 
taken, — as,  for  instance,  in  cholelithiasis  (see  p.  295), — 
a  box  of  the  shape  of  a  drawer  must  be  put  under- 
neath, the  plates  being  inserted  in  place  through  the 
open  side  space  without  dislodging  the  object.  The 
plates  are  always  better  than  the  prints,  many  little 
details  becoming  lost  during  printing. 


ERRORS   OF   SKIAGRAPHY. 

As  mentioned  on  page  286,  false  interpretations  of 
a  skiagraphic  picture  may  be  caused  by  the  shadows 
produced  by  thick  layers  of  bone.  In  fact,  they  can 
hardly  be  avoided  without  a  thorough  knowledge  of  the 
normal  anatomic  relations  of  the  bone  that  produces 
such  shadows. 

As  the  most  minute  gradation  of  density  is  registered, 


3  I  2  APPENDIX. 

the  importance  of  being  thoroughly  acquainted  with  the 
anatomic  relations  of  the  bones  producing  the  doubt- 
ful shadow  is  evident.  The  question,  then,  would  be 
whether  the  supposed  shadow  is  normal  or  not.  On 
certain  portions  of  the  skeleton  the  muscles  and  ten- 
dons would  naturally  cause  obscure  shadows.  The  car- 
pus is  especially  likely  to  produce  such  errors  in  the 
skiagraph  ;  the  tuberositas  ossis  multanguli  majoris,  the 
scaphoid,  the  hamulus  ossis  hamati,  the  os  pisiforme, 
and  the  eminentiae  carpi  volaris  radialis  and  ulnaris 
double  up  the  thickness  of  the  carpus,  thereby  causing 
dark  shadows,  which  might  be  mistaken  for  foreign 
bodies.  Similar  considerations  and  similar  cautions 
apply  to  the  other  diagnostic  opportunities  offered  by 
the  rays. 

If  a  skiagraph  of  the  human  hand,  for  instance,  is 
taken,  the  plate  will  show  the  least  light  where  the 
bones  rest,  while  the  soft  tissues  appear  opaque.  I  here 
is  also  a  difference  of  opacity  according  to  the  thick- 
ness of  the  tissues,  their  blood-supply,  and  their  air- 
capacity. 

The  foot,  while  easily  skiagraphed  in  the  direction  of 
the  dorsum  toward  the  planta  pedis,  from  the  toes  up 
to  the  upper  third  of  the  metatarsus  presents  an 
obstacle  further  backward  in  the  first  and  third  cunei- 
form bones  and  the  scaphoid,  so  that  it  is  necessary 
also  to  skiagraph  the  foot  on  these  portions  transversely 
by  having  the  outer  surface  rest  on  the  support.  It  is 
by  this  procedure  only  that  the  isolated  shadows  of 
the  astragalus,  the  calcaneum,  the  os  cuboideum,  the 
scaphoid,  and  the  fourth  and  fifth  metatarsal  bones 
can  be  distinctly  outlined,  so  that  false  interpretations 
may  be  excluded. 


PRACTICAL    USE    OF    RONTGEN    RAYS.  31 3 

In  the  early  Rontgenian  era  the  normal  sesamoids 
were  also  sometimes  incorrectly  interpreted. 

How  important  is  the  knowledge  of  minute  anatomic 
details,  especially  of  non-pathologic  abnormalities,  will 
be  evident  from  the  fact  that  the  os  intermedium  cruris 
(os  trigonum  tarsi)  has  been  mistaken  for  a  fragment 
severed  from  the  astragalus.  This  bone  is  a  typical 
part  of  the  tarsus  of  all  mammalia,  and  its  frequency  is 
estimated  at  from  seven  to  eight  per  cent. 

Shepherd,*  who  mistook  this  bone  for  a  fractured 
fragment,  says:  "The  fact  that  this  fracture  is  not 
mentioned  in  any  of  the  text-books  of  surgery  or  in 
special  treatises  on  fractures  would  easily  be  accounted 
for  by  its  only  being  discovered  by  dissection  ;  it  causes 
no  deformity,  and  the  symptoms  it  would  give  rise  to 
during  life  would  probably  be  obscure."  The  same 
author  tried  to  produce  this  fracture  artificially  on  the 
cadaver,  but  "in  every  case,"  he  says,  "where  this 
manceuver  was  performed  I  failed,  even  when  the 
greatest  force  was  used,  to  break  off  the  little  process 
of  bone  mentioned  above." 

Pfitzner-j-  regards  the  os  trigonum  tarsi  as  an  inte- 
gral part  of  the  posterior  process  of  the  astragalus  in 
the  adult,  which  is  analogous  to  the  os  intermedium 
antibrachii. 

The  practical  significance  of  this  bone  is  evident 
from  a  case  described  by  Wilmans,  J  which  is  also 
highly  interesting  from  a  medicolegal  standpoint : 

*"  A  Hitherto  Undescribed  Fracture  of  the  Astragalus,"  "Journal  of 
Anatomy  and  Physiology,"  October,  1882. 

f  "  Beitrage  zur  Kenntniss  des  menschlichen  Extremitaatenskelets," 
"  Morphologische  Arbeiten,"  1896,  2  tes  Heft. 

% "  Fortschritte  auf  dem  Gebiete  der  Ronlgenstrahlen,"  Band  11, 
Heft  3. 


314  APPENDIX. 

A  laborer  claimed  that  he  was  injured  by  an  iron  bar 
on  January  20,  1897,  but  was  able  to  work  during  the 
whole  day.  On  the  following  day  he  called  on  Dr. 
Wilmans,  complaining  of  intense  pain  at  his  internal 
malleolus.  He  limped  and  asserted  his  inability  to 
work.  Wilmans  found  a  slight  swelling  below  the 
right  internal  malleolus.  Ecchymosis  of  the  skin  be- 
ing absent,  the  swelling  was  attributed  to  the  presence 
of  a  considerable  degree  of  talipes,  from  which  the 
laborer  suffered  at  the  same  time.  The  leg  was  ele- 
vated and  fomentations  were  applied  for  several  days. 
The  laborer  still  complaining  of  great  pain,  it  was 
decided  to  transfer  him  to  a  hospital  for  observation. 
When  discharged,  after  several  weeks  of  treatment,  the 
laborer  made  an  effort  to  resume  work,  but  at  once 
declared  that  he  was  unable  to  keep  it  up.  He  was 
therefore  admitted  to  another  hospital,  where  he  re- 
peated this  manceuver  several  times  during  a  period  of 
six  months.  Finally  he  claimed  damages  for  having  been 
crippled  by  the  injury  sustained  on  January  20,  1897, 
but  in  view  of  the  negative  objective  condition  found 
by  Dr.  Wilmans,  the  society  decided  not  to  grant  any 
claims.  The  consequence  was  that  the  laborer  was 
transferred  to  the  surgical  division  of  a  third  hospital 
for  further  observation.  There  he  complained  that 
he  had  continuous  pains  below  the  right  external  mal- 
leolus, even  while  in  the  recumbent  position.  The  pain 
increased  while  walking  or  sitting.  Stepping  on  the 
right  heel  he  also  declared  to  be  impossible.  By  dis- 
tracting his  attention,  however,  it  was  noticed  that  he 
could  stand  well  on  his  heel,  and  he  would  undoubtedly 
have  been  declared  a  malingerer,  had  not  the  Rontcren 
rays  come  to  his  rescue,  at  least  temporarily.     A  skia- 


PRACTICAL    USE    OF    RONTGEN    RAYS.  3  I  5 

graph  showed  a  bone-fragment  at  the  junction  of  the 
astragalus  with  the  posterior  surface  of  the  calcaneum. 
On  the  strength  of  this  skiagraphic  "proof"  Dr.  Wil- 
mans,  although  still  mistrusting,  was  forced  to  modify 
his  original  opinion,  and  certified  that  the  patient  suf- 
fered from  "fracture  of  the  astragalus,  in  consequence 
of  which  he  was  damaged  for  life."  The  laborer 
therefore  received  an  annuity  of  thirty  per  cent.,  in 
proportion  to  the  estimated  curtailing  of  his  wages. 

Soon  afterward  the  laborer  was  discovered  by  Dr. 
Wilmans  carrying  a  heavy  weight  without  any  apparent 
pain,  while  formerly  he  had  claimed  to  be  unable  to 
walk  without  a  cane  or  a  crutch.  Dr.  Wilmans  insisted 
upon  a  second  irradiation,  this  time  also  skiagraphing 
the  uninjured  left  foot.  The  skiagraph  showed  the 
"  severed  bone  fragment,"  which  had  first  been  regarded 
as  a  sesamoid  of  the  musculus  flexor  longus  hallucis,  but 
which  was  now  recognized  as  a  normal  os  intermedium 
cruris.  The  society,  of  course,  refused  the  annuity,  and 
the  German  Supreme  Assurance  Court,  to  which  the 
laborer  had  appealed,  not  only  sustained  the  verdict 
of  the  society,  but  also  decided  that  the  laborer  must 
return  the  annuity  which  he  had  unjustifiably  enjoyed 
for  eighteen  months. 

The  significance  of  a  skiagraph  for  the  purpose  of 
estimating  the  degree  of  functional  disability,  while 
great  in  general,  is  not  always  conclusive.  A  skia- 
graph may  show  a  considerable  degree  of  bony 
deformity  after  a  fracture  (compare  Fig.  1 13),  and  still 
the  function  may  hardly  be  disturbed  at  all.  Skia- 
graphic test  has  shown  that,  as  a  whole,  even  our  best 
functional  results  show  by  no  means  an  ideal  union, 
like  figure  32,  for  instance.     An  unscrupulous  patient 


3  I  6  APPENDIX. 

who  secures  possession  of  a  skiagraph  of  his  own  case, 
which  shows  considerable  deformity,  may,  although 
there  is  no  functional  disturbance,  strongly  appeal  to 
a  jury  on  the  strength  of  his  skiagraph,  if  he  succeeds 
in  simulating  great  impairment.  On  the  other  hand, 
there  may  be  but  little  evidence  of  bone-injury  on  the 
skiagraph,  but  there  may  be  severe  impairment  of 
function  on  account  of  the  injury  to  the  soft  tissues 
(circulatory,  trophic,  or  inflammatory  disturbances), 
which  can  be  represented  only  faintly,  if  at  all.  This 
shows  the  necessity  of  considering  all  the  other  clinical 
symptoms  in  connection  with  the  skiagraph. 

While  it  is  easy,  even  for  a  layman,  to  understand 
the  significance  of  most  of  the  skiagraphs  illustrated  in 
this  book,  there  are  injuries  the  correct  interpretation 
of  which  presupposes,  besides  thorough  anatomic 
knowledge,  the  greatest  care  and  a  vast  amount  of 
experience  as  to  the  different  modes  of  delineation  in 
various  projection-planes. 

The  greatest  diagnostic  difficulties  are  offered  by  the 
joints.  The  more  complicated  a  joint  is,  the  more  com- 
plicated the  skiagraphs  of  its  various  positions  will  nat- 
urally appear.  It  is  especially  the  elbow-joint  and  hip- 
joint  which  are  kept  in  view.  First  of  all,  the  interpreta- 
tion of  the  displacement  caused  by  supracondylar  frac- 
ture of  the  humerus,  and  the  deformities  resulting  from 
it  later  on,  may  tax  the  power  of  discrimination  consid- 
erably. 

The  older  the  fracture,  the  less  conspicuous  the 
fracture-line  will  appear,  since  it  will  be  more  or  less 
overshadowed  by  the  callus.  In  old  fractures  the 
line  can  not  be  represented  as  such,  and  it  is  only  in 
case  of  union  in  a  displaced  position  that  its  features 


PRACTICAL    USE    OF    1«">NTGEN    RAYS. 


17 


could  be  guessed.     In  the   case  illustrated  by  figure 
1  29,  for  instance,  a  second  skiagraph  was  taken  three 


Fig.  175. — Congenital  dislocation  of  both  hips  in  a  girl  of  seven  years.  The 
non-ossified  epiphyses  of  the  heads  of  the  femur  must  not  be  mistaken  for  fracture 
fragments. 


years  afterward,   which  showed  essentially  the  same 
features  as   figure    129,  which    had    been   taken  four 


31 8  APPENDIX. 

weeks  after  the  injury.  (Compare  also  Figs.  128,  130, 
and  141.) 

In  the  case  of  entire  absence  of  displacement  it  is 
only  a  very  distinct  skiagraph  that  shows  the  line 
clearly.  (Compare  Fig.  138.)  It  is  natural  that  in  such 
cases  there  is  no  skiagraphic  evidence  after  recovery 
— that  is,  in  from  four  to  ten  weeks,  according  to  the 
type  of  fracture. 

Should  a  court,  for  instance,  doubt,  in  such  an 
event,  that  there  had  been  a  fracture,  a  skiagraph  taken 
after  such  a  period  might  show  a  negative  result, 
although  there  surely  was  a  fracture.  In  the  case  illus- 
trated by  figure  109  the  very  distinct  skiagraph,  taken 
only  two  months  after  the  injury,  showed  no  signs  of  a 
fracture 

In  the  case  illustrated  by  figure  32,  where  no  dis- 
placement existed,  there  was  only  a  faint  fracture-line, 
but  the  presence  of  the  callus  left  no  doubt  as  to  the 
previous  existence  of  a  fracture.      (Also  compare  Fig. 

I-75-) 

On  the  other  hand,  callus  formation  may  be  so  abun- 
dant (Figs.  87  and  88)  that,  in  spite  of  the  absence  of 
displacement,  the  fullest  evidence  of  fracture  may  still 
be  furnished  after  months. 

The  intra  articular  fracture  types  offer  the  greatest 
diagnostic  difficulties,  inasmuch  as  the  fracture-line  is 
also  often  obscured  by  the  callus  formation.  (Com- 
pare Figs.  46  and  52.)  If,  however,  a  skiagraph  of  the 
other  joint  is  made  at  the  same  time,  in  the  same  posi- 
tion, and  in  the  same  projection,  the  various  delinea- 
tions of  the  shadows  will  be  correctly  understood  and 
interpreted. 

A  normal  skeleton  should  also  always  be  compared 


PRACTICAL    USE    OF    RONTGEN    RAYS.  319 

on  the  skiagraph.  It  should  particularly  be  remembered 
that  certain  pathologic  conditions — such  as  rachitis, 
for  instance — influence  the  outlines  of  the  bones  and 
may  deceptively  be  supposed  to  represent  a  portion 
of  an  injury.  In  such  an  event  the  skiagram  of  the 
fellow-extremity  will  set  matters  right.  (Compare  case 
described  on  p.  314.) 

In  very  young  children  the  eminentia  capitata  (Fig. 
177)  appears  as  if  entirely  severed  from  the  humerus, 
although  the  relations  are  normal.  The  explanation 
of  this  important  phenomenon  is  that  the  epiphyseal 
tissues  are  not  sufficiently  ossified  to  produce  a  shadow 
on  the  plate.  If  these  points  are  not  thoroughly  con- 
sidered, a  displaced  fracture-fragment  might  be  erro- 
neously diagnosticated. 

As  referred  to  on  page  74,  union  between  the  epi- 
physis and  the  diaphysis  of  the  head  of  the  humerus  is 
not  perfect  before  the  twentieth  year.  (Compare  Fig. 
32.)  The  lower  epiphysis  of  the  humerus  consists  of 
four  nuclei,  which  do  not  ossify  before  from  the  eighth 
to  the  seventeenth  year.     (See  Figs.  176,  177.) 

The  epiphyses  of  the  trochlea  as  well  as  of  the 
olecranon  do  not  ossify  before  between  the  seventh 
and  the  twelfth  years,  which  explains  why  an  osseous 
nucleus  that  is  still  connected  with  its  neighboring 
epiphyseal  nuclei  and  the  diaphysis  by  cartilaginous 
tissue  appears  as  an  isolated  piece  of  bone  which 
might  erroneously  be  taken  for  a  fragment.  (Com- 
pare Fig.  176.) 

The  acromioclavicular  junction  sometimes  shows  in 
the  skiagraph  a  hiatus  of  the  width  of  a  finger,  so  that 
a  diastasis  of  the  joint  might  be  assumed.  (See  Figs. 
1 6  and  21.)     But  since  our  knowledge  on  this  new  sub- 


320  APPENDIX. 

ject  has  increased,  we  know  that  this  apparent  diastasis 
is  by  no  means  pathologic,  and  that  there  is  a  normal 
gap  between  the  osseous  ends  of  the  acromion  and 
the  acromial  end  of  the  clavicle. 

The  upper  epiphysis  and  the  diaphysis  of  the  radius 
(see  Figs.  46,  49)  unite  between  the  seventeenth  and 
the  eighteenth  year,  and  its  lower  epiphysis  and  dia- 


Fig.  176. — Elbow-joint  in  a  boy  often  years,  four  hours  after  backward  dis 
location  of  radius  and  ulna  had  occurred  and  two  hours  after  reduction.  The  non- 
ossified  connection  of  the  lower  epiphysis  of  the  humerus  appears  like  a  fracture- 
line,  but  the  relations  are  perfectly  normal  with  the  exception  of  the  dark  shades 
in  the  soft  tissues,  which  represent  the  bloody  effusions  caused  by  the  injury. 

physis  join  in  the  twentieth  year.  (Compare  Figs. 
76,  87.)  During  the  early  Rontgenian  era  the  trans- 
lucent space  above  the  epiphyseal  cartilage  in  children 
was  erroneously  taken   for  a  fracture-line.      (Fig.  73.) 

The  head  of  the  femur  unites  with  the  diaphysis  at 
the  eighteenth  or  nineteenth  year  (compare  Fig.  109), 
and  the  lower  epiphysis  follows  after  the  twentieth 
year.     (Compare  Figs.  118  a  and  140.) 

The  upper  epiphysis  of  the  tibia  unites  with  the  dia- 


PRACTICAL    USE    OF    RONTGEN    RAYS.  32 1 

physis  in  the  twentieth  or  twenty-second  year  (Figs.  1 18 
a  and  140),  while  the  lower  tibial  epiphysis  unites  with 
the  diaphysis  between  the  eighteenth  and  the  nine- 
teenth year.      (Compare  Fig.  137  and  Frontispiece.) 

As  to  the  different  periods  of  ossification  of  the  pel- 
vis and  the  normal  translucent  spaces  in  children,  com- 
pare figures  109,  113,  and  175. 

For  the  thorough  interpretation  of  skiagraphs  in 
children,  it  is  important  to  know  that  at  birth  the  dia- 
physes  of  the  radius,  the  ulna,  the  metacarpal  bones, 
and  the  phalanges  are  ossified,  while  their  epiphyses, 
as  well  as  the  whole  carpus,  are  still  cartilaginous.  It 
is  not  before  the  seventh  year  that  an  osseous  nucleus 
shows  at  the  lower  epiphysis  of  the  ulna.  Union  with 
the  diaphysis  sometimes  begins  with  the  twelfth  year, 
but,  as  a  rule,  not  before  the  fifteenth.  Even  then  a 
small  epiphyseal  disc  remains,  which  does  not  dis- 
appear before  the  seventeenth  year  in  the  female,  and 
not  before  the  nineteenth  year  in  the  male. 

As  to  the  osseous  nucleus  of  the  lower  end  of  the 
radius,  compare  page  74. 

The  osseous  nuclei  of  the  carpus  show  at  different 
periods — viz.,  at  the  os  capitatum,  at  the  fourth  month  ; 
at  the  hamatum,  at  the  fifth  month  ;  while  the  trique- 
trum  shows  its  nucleus  between  the  second  and  the 
third  year,  the  lunatum  between  the  third  and  the  fifth, 
the  naviculare  between  the  fifth  and  the  seventh,  the 
trapezium  and  the  trapezoid  between  the  sixth  and  the 
seventh  year,  and  the  os  pisiforme  between  the  eleventh 
and  the  fifteenth  year. 

After  five  years  the  capitatum,  hamatum,  and  tri- 
quetrum  have  assumed  their  regular  shapes,  while  the 


322  APrENDIX. 

others,  with  the  exception  of  the  pisiforme,  are  per- 
fectly developed  at  the  twelfth  year. 

The  osseous  nuclei  of  the  epiphyses  of  the  metacar- 
pal bones  show  at  the  second  year,  their  synostosis 
with  the  diaphysis  taking  place  between  the  twelfth  and 
the  seventeenth  year  in  the  female,  and  at  the  age  of 
nineteen  in  the  male.  The  epiphyseal  nuclei  of  the 
phalanges  are  ossified  between  the  fourth  and  the  fifth 
year,  their  synostosis  with  the  diaphysis  taking  place 
at  the  same  age  as  that  of  the  metacarpal  bones  (from 
the  twelfth  to  the  seventeenth  year  in  the  female,  and 
between  the  sixteenth  and  the  nineteenth  year  in  the 
male). 

Regarding  the  elbow-joint,  it  must  be  considered 
that  an  osseous  nucleus  appears  at  the  interior  of 
the  capitulum  humeri  between  the  second  and  the 
third  year,  another  one  in  the  internal  epicondyle 
at  the  fifth  year,  a  third  in  the  trochlea  between  the 
eleventh  and  the  twelfth  year,  and  soon  afterward  a 
fourth  in  the  external  epicondyle.  The  nucleus  of  the 
internal  epicondyle  unites  with  the  diaphysis  between 
the  sixteenth  and  the  twentieth  year ;  but  the  other 
three  nuclei  form  a  synostosis  among  themselves  at 
the  seventeenth  year,  and  then  form  the  uniform 
osseous  epiphysis,  which  completes  its  synostosis  with 
the  diaphysis  at  about  the  twentieth  year.  (Compare 
Figs.  176  and  177.) 

In  the  capitulum  radii  an  osseous  nucleus  appears 
between  the  fifth  and  the  seventh  year,  and  in  the 
olecranon  between  the  sixth  and  the  eighteenth  year, 
both  uniting  with  the  diaphysis  between  the  twentieth 
and  the  twenty-fifth  and  between  the  sixteenth  and 
the  twentieth  year. 


PRACTICAL    USE    OF    RONTGEN    RAYS. 


O- J 


Regarding  the  knee-joint,  it  must  be  considered  that 
the  lower  femoral  epiphysis  contains  an  osseous 
nucleus  at  birth,  while  the  nucleus  in  the  tibial  epiphy- 
sis shows  shortly  afterward.  At  the  fourth  year  both 
these  epiphyses  have  completed  their  development, 
but  they  do  not  unite  with  the  diaphysis  before  the 
fifteenth  year.  The  anatomic  text-books  say  that 
union  takes   place   between   the   seventeenth  and  the 


Fig.  177. — Showing  fracture  of  internal  condyle,  but  normal  erainentia  capi- 
tata,  the  latter  appearing  severed  from  the  humerus,  in  a  boy  of  nine  years.  The 
perfectly  normal  radial  epiphysis  also  appears  severed. 

twenty-fourth  year,  but  skiagraphic  experience  points 
to  an  average  period  of  only  sixteen. 

The  osseous  epiphyseal  nucleus  of  the  fibula  appears 
between  the  second  and  the  fifth  year,  and  unites  with 
the  diaphysis  between  the  eighteenth  and  the  twenty- 
fifth  year;  but  skiagraphy  dates  this  period  earlier — 
viz.,  the  fifteenth  year.  The  osseous  nucleus  in  the 
tibial  spine  appears  between  the  eighth  and  the  tenth 
year ;  the  epiphyseal  line  disappears  between  it  and 
the  diaphysis  at  the  fifteenth  year. 


324  APPENDIX. 

As  to  the  bones  of  the  foot,  it  may  be  said  that  the 
lower  epiphyses  of  the  tibia  and  the  fibula  show  their 
osseous  nuclei  in  the  first  and  second  years,  and  unite 
with  the  diaphysis  between  the  eighteenth  and  the 
twenty-fifth  year  ;  according  to  skiagraphs,  as  early  as 
before  the  eighteenth  year.  The  osseous  nucleus  of 
the  astragalus  and  calcaneum  appears  intra  utero,  that 
of  the  cuboid  shortly  before  or  after  birth,  that  of  the 
cuneiformia  between  the  first  and  the  fifth  year,  and 
that  of  the  os  naviculare  from  the  first  to  the  fifth  year. 
The  osseous  nuclei  of  the  metatarsal  bones  and  of  the 
phalanges  appear  from  the  second  to  the  tenth  year, 
and  unite  with  the  diaphyses  between  the  sixteenth 
and  the  twenty-second  year. 

In  joint  fractures  occurring  in  childhood  it  is  neces- 
sary, therefore,  to  take  at  least  two  skiagraphs  in  differ- 
ent projection-planes  and  to  compare  them  thoroughly 
with  the  normal  fellow.  In  a  case  of  fracture  of  the 
femoral  head,  for  instance,  the  deformity  had  appeared 
three  times  as  large  as  it  actually  was,  on  account  of 
inappropriate  projection.  The  degree  of  shortening 
of  the  limb  was  overestimated  accordingly.  This  shows 
the  necessity  of  considering  the  other  clinical  symp- 
toms and  data  in  connection  with  the  skiagraph. 

In  fractures  of  childhood  it  should  also  be  remem- 
bered that  the  process  of  ossification  is  influenced  by 
various  affections  of  the  bone,  as,  for  instance,  in 
rickets. 

How  important  the  question  of  projection  is  be- 
comes evident  when  we  consider  that  grave  errors 
may  sometimes  occur  even  if  all  the  preliminary  con- 
ditions required  for  a  thorough  understanding  of  the 
case  seem  to  be  fulfilled.     This  will  appear  from   the 


PRACTICAL  USE  OF  RONTGEN  RAYS.        325 

following   experience,    which    has   probably   not   been 
paralleled  in  the  literature  of  this  subject: 

A  boy  four  years  of  age,  while  playing  on  the  street, 
fell  against  an  iron  bar.  Being  unable  to  rise  again, 
he  was  taken  up  and  carried  to  St.  Mark's  Hospital, 
where  in  the  first  instance  moderate  pain  was  noted 
besides  the  functional  disturbance.  There  was  neither 
any  difference  in  level  or  any  other  deformity,  nor  any 
shortening  or  the  typical  equinus  position.  A  photo- 
graph taken  two  days  after  the  injury  only  showed  a 
very  moderate  and  uniform  swelling  of  the  leg.*  Ab- 
normal mobility  and  crepitus,  in  accordance,  could  be 
produced  only  by  very  rough  manipulations. 

On  the  day  following  the  injury  two  skiagraphs 
were  made  in  different  positions  ;  one  of  them  (Fig. 
137)  in  the  dorsal  and  the  other  (Fig.  139,  A)  in  the 
lateral  position.  To  my  surprise,  figure  137 — which 
had  been  skiagraphed  by  a  direct  irradiation,  the  cen- 
ter of  the  platinum  disc  of  the  tube  being  perpendicu- 
lar to  the  anterior  surface  of  the  leg — did  not  show  the 
slightest  indication  of  a  fracture,  while  figure  139,  A 
(also  compare  Frontispiece),  which  represents  the  leg 
irradiated  from  the  outer  aspect  of  the  tibia,  shows  a 
marked  fracture-line. 

The  fracture  presented  the  typical  oblique  type  in 
the  middle  of  the  tibia,  the  fracture-line  running  from 
below  anteriorly  to  above  posteriorly,  the  upper,  taper- 
ing fragment  overlapping  the  lower  end.  No  sideward 
displacement  having  been  present,  it  can  be  under- 
stood why  the  rays,  reaching  the  long  axis  of  the  tibia 
in  a  vertical  direction,  do  not  show  the  fracture-line. 

*  Photograph  published  in  "New  York  Medical  Journal,"  January  6, 
1900. 


326  APPENDIX. 

A  very  slight  change  in  the  position,  where  the  inclina- 
tion toward  the  fibular  direction  amounts  to  less  than 
one  millimeter,  brought  out  the  fracture  distinctly. 

Now,  if  I  had,  as  is  the  custom  in  general,  taken  a 
skiagraph  in  the  anteroposterior  direction  only,  and  if 
the  manipulations  made  during  the  first  examination 
were  carried  out  as  gently  as  they  properly  should 
be,  the  fracture  might  have  been  overlooked  entirely. 
And  if,  in  view  of  the  local  pain  and  tenderness,  the 
swelling-,  .and  the  functional  disturbance,  the  possibility 
of  a  fracture  would  have  been  seriously  considered, 
the  skiagraph  (Fig.  137)  might  have  silenced  the 
uneasy  conscience. 

This  experience  teaches  the  necessity  of  adopting  the 
principle  of  always  taking  at  least  two  skiagraphs  in  two 
different  positions  in  all  cases  of  suspected  fracture. 

The  medicolegal  aspects  of  a  case  of  this  kind  need 
no  further  comment. 

In  taking  skiagraphs  of  foreign  bodies  it  must  be 
considered  that  their  size  varies  according  to  the  dis- 
tance  from  the  tube.  (Compare  p.  305.)  In  oblong 
bodies  great  errors  as  to  their  extent  may  be  com- 
mitted. The  author  once  was  very  much  surprised  in 
a  case  where  a  needle-fragment  had  entered  the  palm 
of  the  hand  in  a  perpendicular  direction.  The  plate, 
while  indicating  the  presence  of  the  needle  distinctly, 
created  the  impression  that  the  fragment  was  only 
about  two  millimeters  in  length.  When  extracted  it 
was  found  to  be  more  than  an  inch  long,  the  rays 
having  reached  the  hand  in  a  perpendicular  direction, 
so  that  the  circumference  of  the  fragment  was  repro- 
duced rather  than  its  length.  A  side  view,  of  course, 
would  have  cleared  up  the  error  at  once. 


PRACTICAL    USE    OF    RONTGEN    RAYS.  327 

Misinterpretations  have  also  arisen  from  unavoid- 
able mechanical  and  chemic  defects,  causing  markings 
in  the  photographic  plate,  the  significance  of  which 
must  be  well  known  to  the  skiagraphic  interpreter. 

Blemishes  may  be  produced  by  spots  caused  by  pus 
from  wounds  or  by  perspiration. 

In  the  location  of  foreign  bodies,  especially  in  the 
skull,  many  errors  were  and  are  still  committed.  As 
to  their  avoidance,  compare  pages  265  and  306. 

In  drawing  conclusions  from  skiagraphs  it  should 
especially  not  be  lost  sight  of  that  a  skiagraph  is  by 
no  means  a  photograph  of  an  object,  but  a  silhouette 
— that  is,  a  photograph  of  its  shadow. 


INDEX. 


Abdominal   plaster-of-Paris   dressing, 

1 86 
Acromegaly,  28S 
Acromioclavicular  junction,  319 
Acromion,  fracture  of,  90 
Adhesions,  33 

in   fracture   of  lower  end  of  radius, 
142 
Adhesive  plaster  in  extension  treatment, 

5o 
Air-brake  wheel,  279 
Air  expired  by  the  surgeon,  54 
Alternating  current,  280 
Alveolar  process,  fracture  of,  271 
Ambulatory  dressing,  42 

in  fracture  of  femur,  187 
in  supramalleolar  fracture,  208 
Anesthesia,  37 
Aneurysm,  32 

of  the  aorta,  291 

of  the  thigh,  289 
Ankle-joint,   inflammatory    process  in, 
213 

dislocation  of,  214 
Ankylosis,  33 

of  knee-joint,  190 

treatment  of,  72 
Anode,  280 
Antibrachium,  backward  dislocation  of, 

109 
Antrum   Highmori,   osteoplastic    resec- 
tion of,  265 
Aortic  aneurysm,  291 
Arteriosclerosis,  292 
Arthritis,  simple,  288 
Asepsis  in  compound  fractures,  51 

in  puncturing  extravasations,  198 

intra-oral,     in     fracture     of    inferior 
maxilla,  274 
Astragalus,  alleged  fracture  of,  315 

fracture  of,  226 
Atmospheric  infection,  52 
Atrophy,  ^3 
Axial  displacement,  18 
Axillary  dislocation,  98 


Backward  dislocation  of  ankle-joint, 
214 
of  forearm,  109 

displacement  in  fracture  of  lower  end 
of  tibia,  222 
Bactericidal   influence  of  the  RSntgen 

rays,  303 
Base  of  skull,  fracture  of,  285 
Battle-field,  immobili?ation  on  the,  39 
Beck's    dressing    for     fracture    of    the 
clavicle,  87 

operating  table,  41 
Bernard's,  Claude,  sign,  253 
Bladder,  paresis  of,  in  fracture  of  spinal 

column,  241 
Blemishes  of  photographic  plates,  327 
Blood-ferment,  absorption  of,  26 
Body,  scapular,  fracture  of,  89 
Bone-suture,  70 
Bony  ankylosis,  33 
Bracelet  for  fracture  of  lower    end  of 

radius,  143,  152 
Brachial  plexus  in    fracture   of   spinal 

column,  242 
Buck's  extension,  49 
Bullets  in  the  skull,  252 

in  the  thoracic  cavity,  292 


Calcaneum,  fracture  of,  229 
Calcareous  areas  in  the  lungs,  290 
Calculi,  biliary,  295 

renal,  294 

vesical,  294 
Callus-formation,  27,  318 

in  fracture  of  lower  end  of  humerus, 
120 

in  fracture  of   lower  end    of   radius, 

.155 
Capitulum  humeri,  separation  of,  119 
Carcinoma  of  esophagus,  skiagraphy  of, 
294 
of  pylorus,  skiagraphy  of,  294, 
Carpus,  fracture  of,  161 
osseous  nucleus  of,  321 


529 


INDEX. 


Cartilages  of  joints,  288 
Cathode,  2S0 
Cathode-ray,  10 
Cerebral  abscess,  261 

commotion,  253 

compression,  254 

contusion,  255 
Cerebrospinal  fluid,  escape  of,  in  frac- 
ture of  base  of  skull,  267 
Cervical  vertebrae,  fracture  of,  241 
Change  of  knife  after  skin-incision,  57 
Children,  fracture  of  skull  in,  73 

peculiarities  of  fractures  in,  73 
Chondro-epiphyseal  separation  of  lower 

end  of  radius,  139 
Clavicle,  fracture  of,  78 
Classification  of  fractures,  17 
Coaptation-splints  in  fracture  of  femur, 

186 
Coccygodynia,  288 
Coccyx,  fracture  of,  30,  288 
Collar-splint,  44 
Colles'  fracture,  145 
Comminuted  fracture,  19 
Commotion    in    fracture    of     vertebral 

bodies,  241 
Complete  fractures,  18 
Compound  fractures,  1 8,  34 
asepsis  in,  51 
of  radius  and  ulna,  159 
Compression    in    fracture    of   vertebral 

bodies,  241 
Congenital  dislocation  of  hip,  287 

fractures,  73 
Consolidation,  time  for,  29 
Constitutional  causes  of  non-union,  32 

diseases  causing  fractures,  17 
Contusions,  differentiation   in  general, 

24 
Coracoid  process,  fracture  of,  92 
Coronoid  process  of  ulna,  fracture   of, 

125 
( 'ostal  cartilages,  fracture  of,  237 
Crepitus,  21 
Crookes,  IO 

Cubital  process,  fracture  of,  1 15 
Cuboid  bone,  fracture  of,  231 
Cuneiform  bone,  fracture  of,  23 1 
Current,  alternating,  280 
Cystitis  in   fracture   of  spinal   column, 

241 


DECUBITUS  in  fracture  of  spinal  column, 

244 
Defects  of  photographic  plates,  327 
Deformity,  22 


Delirium  tremens,  34 
treatment  of,  72 
Dental  splint,  274 

Dentistry,  use  of  Rontgen  rays  in,  304 
Depilation  caused  by  Rontgen  rays,  301 
Dermatitis  caused  by  Rontgen  rays,  300 
Diacondylar  fracture  of  lower   end  of 

humerus,  1 13 
Diagnosis,  23 

Diastasis  in  fracture  of  patella,  200 
Direct  current,  277 

fractures,  17 
Disability,  functional,  315 
Dislocation,  differentiation  in  general, 
24 

of  antibrachium,  109 

of  hip,  287 
Displacement,  absence  of,  35 
Disposition  to  infection,  58 
Dissemination   of   force   in   fracture   of 

skull,  249 
Distance  of  plate  from  tube,  305 
Distortion,  differentiation  between  frac- 
ture of  external  malleolus  and, 
225 
between  fracture  of  lower  end  of 
tibia  and,  220 
Disturbances  in  process  of  repair,  31 

of  nutrition  of  bones,  17 
Dorsal  dislocation  of  thumb,  162 
Dosage  in  skiagraphy,  301 
Dressing,  change  of,  68 
Dust  in  the  operating  room,  53 
Dwarfs,  epiphysis  in,  75 


ECCHYMOSIS,  23 

Echinococcus,  skiagraphy  of,  294 
Eczema  treated  by  Rontgen  rays,  301 
Edema,  39 

of  foot,  231 
Edison-Lalande  cells,  277 
Elbow-joint,  osseous  nucleus  of,  322 
Electric  current,  277 
Embolism,  32 

treatment  of,  J I 
Emergency  cases,  treatment  of,  37,  39 
Eminentia  capitata  humeri,  separation 

of,  119 
Encephalitis  in  fracture  of  skull,  261 
Enchondroma,  289 

of  larynx,  293 
Enophthalmos  in  fracture  of  orbit,  264 
Epicondylar  fracture  of  humerus,  115 
Epiphyseal  separation,  73,  76 
of  lower  end  of  radius,  139 


INDEX. 


00 


U 


Exophthalmos    in    fracture  of   base  of 

skull,  266 
Exposure,  length  of  time  of,  305 

of  skin-bacteria,  57 
Extension-dressings,  39 
External  epicondyle,  fracture  of,  116 

malleolus,  fracture  of,  225 
Extravasation,  treatment  of,  38 


Facial  bones,  fracture  of,  268 

False  mobility,  causes  of,  31 

Faraday,  9 

Fat-embolism,  26 

Faulty  position  after  fracture  of  femur, 

181 
Femur,  epiphyseal  cartilage  of,  320 
separation  of  lower  end  of,  190 
of  upper  end  of,  1 68 

extracapsular  fracture  of  neck  of,  172 

fracture  of  diaphysis  of,  179 
of  lower  third  of,  183 
of  middle  of,  184 
of  neck  of,  169 
of  upper  end  of,  168 

infratrochanteric  fracture  of,  179 

intta-articular  severing  of  a  piece  at 
the  lower  end  of,  192 

intracapsular  fracture  of,  170 

isolated  fracture  of  trochanter  major 
of,  177 
Fenestrated    plaster-of-Paris    dressing, 

41 
Fiber,  splints  made  of,  48 
Fibroma,  289 
Fibrous  ankylosis,  23 
Fibula,  abnormal  development  of,  217 

isolated  fracture  of,  223 

osseous  nucleus  of,  323 

pseudarthrosis  of,  226 

simultaneous    fracture   of  tibia  and, 
205 
Finger,  fracture  of,  161 
Finger-nails,  cleaning  of,  60 
Firearms,  effect  of  modern,  255 
Fissure,  20 

of  lower  end  of  radius,  139 
Fixation  of  fragments,  35 
Fixed  dressings,  39 
Floating  bodies  in  knee-joint,  287 
Fluorescing  screen,  284 
Fluoroscope,  284 
Fluoroscopic  examination,  308 
Foot,  fractures  of,  226 

osseous  nuclei  of,  324 

position  of,  in  skiagraphy,  307 
Foot-board,  50 


Foot-edema  of  soldiers,  231 

Forceps,  Beck's,  for  fastening  napkins 
to  the  wound-margins,  64 

Forearm,  fractures  of,  121 

position  of,  in  skiagraphy,  306 

Foreign  bodies,  286,  326 
in  the  eye,  288 
in  the  skull,  288 
location  of,  306 

Forward  dislocation  of  ankle-joint,  214 

Functional  disability,  22 

Fusion  of  radius  and  ulna  after  radial 
fracture,  159 
of  radius  and  ulna  after  ulnar  frac- 
ture, 129 


Gall-bladder,  skiagraphy  of,  297 
Gall-stones,    chemic    composition    of, 
296 

skiagraphy  of,  295 
Gangrene,  32,  39 

caused  by  the  Rontgen  rays,  300 
Geissler,  10 

Glands  containing  bacteria,  56 
Glisson's  cradle   in   fracture   of  spinal 

column,  241 
Gloves  during  operation,  60 
Gowns,  sterilized,  64 
Graefe's  head-band,  271 
Green-stick  fracture  in  children,  76 
Gunshot  fracture,  19 
of  skull,  252 


Hand,  fracture  of  bones  of,  161 
position  of,  in  skiagraphy,  307 

Hands  of  surgeon,  sterilization  of,  60 

Head,  fracture  of  radial,  132 

Heart,  injury  to,  in  fracture  of  rib,  237 
skiagraphy  of,  291 

Hemorrhage  from  the  ear  in  fracture  of 
base  of  skull,  266 
from  pharynx  in  fracture  of  base  of 
skull,  266 

Hemothorax  in  fracture  of  rib,  235 

Hertz,  9 

Hip-joint,  dislocation  of,  287 
position  of,  in  skiagraphy,  307 

Hittorf,  10 

Humeroradial  joint,  position  of,  in  ski- 
agraphy, 307 

Humero-ulnar  joint,  position  of,  in  ski- 
agraphy, 307 

Humerus,    appearance    of   nucleus  in, 

.74 

diacondylar  fracture  of,  1 13 


INDEX. 


Humerus,  epicondylar  fracture  of,  1 15 
epiphyseal  cartilage  of,  319 
fracture  of  anatomic  neck  of,  92 
of  diaphysis  of,  105 
of  lower  end  of,  108 
of  surgical  neck  of,  94 
of  tuberculum  majus  or  minus  of, 

104 
of  upper  end  of,  92 
intercondylar  fracture  of,  118 
supracondylar  fracture  of,  108 
transtubercular  fracture  of,  103 
traumatic    epiphyseal    separation    of 
lower  end  of,  1 14 
of  upper  end  of,  101 
Hydronephrosis,  294 
Hydropneumothorax,  290 
Hyoid  bone,  fracture  of,  275 
Hyperesthesia  in  fracture  of  the  spinal 

column,  243 
Hypertrichosis,   301 
Hypertrophied  pleura,  290 
Hypostatic  pneumonia,  42 

Iliac  dislocation  of  femur,  175 
Immobilization,  38 

Implantation  in  non-union  of  bones,  69 
Impacted  extracapsular  fracture  of  neck 
of  femur,  176 

fracture,  19 

fragment  in  fracture  of  skull,  259 
Incomplete  fractures,  18,  19 
Indirect  fractures,  18 
Infantile  paralysis,  fragility  of  bones  in, 

75 
Infected  compound  fracture,  65 
Inferior  maxilla,  fracture  of,  272 
Inflammatory    processes    causing    frac- 
tures, 17 
Infraction,  19 

of  lower  end  of  radius,  139 
Infratrochanteric  fracture,  179 
Inner  table,  protrusion  of,  251 
Intercostal  artery,  injury  to,  in  fracture 

of  rib,  233 
Internal  epicondyle,  fracture  of,  1 15 
Interposition  of  soft  tissues,  31,  182 
Interrupted  plaster-of-  Paris  dressing,  45 
Intracutaneous  bacteria,  56,  199 
Intrauterine  fracture,  19,  73>  7^ 
Intubation  in  fracture  of  larynx,  275 
Iodin  tincture  as  a  prophylactic  disin- 
fectant, 200 
Iodoform-glycerin  as  a  tracer,  288 
Ischemic  symptoms  in   tight  dressing, 
43 


Isolated  fracture  of  upper  end  of  fibula, 
223 
of  upper  end  of  tibia,  216 
Ivory  pegs   in  operation  for  non-union 
of  bones,  69 


Knee,  intra-articular  separation  in,  192 

Knee-joint,  normal  view  of,  191 
osseous  nuclei  of  bones  of,  323 
position  of,  in  skiagraphy,  307 

Kriig- jorgensen  rifle,  255 

Kyphosis,     traumatic,    in    fracture    of 
vertebral  bodies,  240 


Laminectomy,  245 
Larynx,  fracture  of.  275 
Late  callus-formation,  30 
Lateral  dislocation  of  thumb,  163 

displacement,  18 
Leg,  epiphyseal  separation  of,  205 

fracture  of,  204 

position  of,  in  skiagraphy,  307 
Lenard,  10 
Lime-wood  splints,  48 
Line  of  fracture  in  children,  76 
Local  cause  of  non-union,  31 
Localization,    intracranial,    of    bullets, 

263 
Localized  pain,  23 
Longitudinal  displacement,  iS 

fractures,  18 
Lung-abscess,  skiagraphy  of,  291 
Lupus  treated  by  Rontgen  rays,  302 


Malleolar  fracture,  211 

Manual  examination,  24 

Marbles  in  after-treatment  of  fracture  of 
lower  end  of  radius,  143 

Massage  in  after-treatment,  51 

Massage-treatment  in  extravasation,  38 

Maxwell,  9 

Measurement,  24 

Mechanical  cause  of  gangrene,  32 

Mediastinal  tumors,  290 

Medullary  contusion  in  fracture  of  ver- 
tebral bodies,  240 

Meningitis  in  fracture  of  skull,  261 

Meningocele,  299 

Mental  portion  of  inferior  maxilla,  273 

Metacarpus,    epiphyseal    cartilages    of, 
321 
fracture  of,  163 
osseous  nucleus  of,  322 

Metatarsal  bones,  fracture  of,  231 


INDEX. 


33 


O^J 


Mobility,  abnormal,  21 
Molded  plaster  splints,  44 
Moss-board  in  compound  fracture,  66 

in  fracture  of  inferior  maxilla,  274 
Multiple  fracture,  19 
Muscular  contraction  causing  fracture, 

18 
Myelocystocele,  300 
Myelomeningocele,  300 


N/EVUS  vasculosus    treated   by    Ront- 

gen  rays,  301 
Nails  in  operations  for  non-union,  69 
Nasal  bones,  fracture  of,  268 
Neck,  radial,  fracture  of,  134 

scapular,  fracture  of,  89 
Necrosis,  288 

of  bone-ends,  30 
Nelaton's  tbeory  in   fracture  of  lower 

end  of  radius,  139 
Nerve,  compression  of,  71 

insult  to  a,  32 
Neuralgia  in  fracture  of  spinal  column, 

243 
Neurorrhaphy   in   laceration   of   radial 

nerve,  133 
Non-reduction  of  fragments,  36 
Non  union,  69 


Oblique  fractures,  18 

Obstetrics, value  of  Rontgen  rays  in,  2S7 

Olecranon,  fracture  of,  122 

osseous  nucleus  of,  322 
Os  intermedium  cruris,  313 

trigonum  tarsi,  313 
Osteoarthropathie    hypertrophiante 

pneumique,  288 
Osteoblastic  cells,  27 
Osteochondroma,  289 
Osteo-epiphyseal    separation   of    lower 

end  of  radius,  141 
Osteoma,  289 
Osteomyelitis,  288 

of  tibia,  differentiation  between  frac- 
ture and,  213 
Osteoplastic  resection,  287 

of  skull,  259 
Osteopsathyrosis,  17 
Osteosarcoma,  102,  289 
Overriding  of  fragments,  3 1 


Pain  in  infantile  fracture,  76 
Paralysis  in  fracture  of  spinal  column, 
243 


Paralysis  in  fracture  of  skull,  253 
Parasitic  skin  diseases  treated  by  Ront- 
gen rays,  302 
Patella,  fracture  of,  193 
comminuted,  195 
compound,  204 
transverse,  195 
wiring  of,  201 
Pelvic  ring,  fracture  of,  167 
Pelvis,  fracture  of,  166 
Pericarditis  in  fracture  of  rib,  235 
Periostitis  ossificans,  27 
Peripheral  displacement,  19 
Permanent  extension,  49 
Phalanges,  digital  fracture  of,  165 
epiphyseal  cartilages  of,  321 
osseous  nucleus  of,  322 
tarsal,  fracture  of,  231 
Photographic  plate,  285 
Phrenic    nerve    in    fracture    of    spinal 

column,  247 
Plaster-of- Paris    bandage,  making    of, 
40 
dressing,  40,  77 

disadvantages  of,  47 
in  wound  treatment,  40 
removal  of,  41 
Pleura,  hypertrophy  of,  290 
Pleuritis  sicca  in  fracture  of  rib,  235 

skiagraphy  in,  289 
Pneumonia,  34 

in  fracture  of  rib,  235 
treatment  of,  72 
Pneumothorax  in  fracture  of  rib,  235 
Position  in  skiagraphy,  306 

of  tube,  307 
Pott's  fracture,  211 
Powell's  electric  saw,  259,  260 
Preglenoid  dislocation,  93,  99 
Pressure  of  bone-fragments,  36 
Projection  in  skiagraphy,  324 
Prolonged  immobilization,  ^3 
Pseudarthrosis    in    fracture     of     anti- 
brachium,  159 
of  femur,  189 
of  fibula,  226 
of  humerus,  107 
in  simultaneous  fracture  of  radius  and 
ulna,  156 
Psoriasis    treated     by     Rontgen    rays, 

301 
Puncturing  in  extravasation,  38 
Pulmonic  tumors,  290 
Putrid  cavities,  treatment  of,  67 
Pyelonephritis    in    fracture    of    spinal 

column,  241 
Pyothorax,  289 


14 


INDEX. 


Rachitic  deformities,  287,  324 
Radial  nerve,  laceration  of,  133,  135 

embedded  in  callus,  135 
Radius,  appearance  of  nucleus  in,  74, 
322 
epiphyseal  cartilage  of,  350,  321 
extra-articular    complete    fracture  of 

(Colles'),  145 
fracture  of,  132 

and  ulna  together,  156 
head  of,  132 
lower  end  of,  136 

combined    with    fracture     of 
styloid  process  of  ulna,  154 
combined    with     fracture    of 
ulnar  head,  153 
neck  of,  134 
shaft  of,  1 35 
Rectum  in  fracture  of  spinal   column, 

243 
Refracturing  femur  for  deformity,  189 
Registration  of  skiagrams,  311 
Renal  calculi,  294 
Repair  in  fractures,  26 
Reposition  of  fragments,  35 
Rheostat,  280,  309 
Rheumatism,  288 
Rib,  compound  fracture  of,  237 
fracture  of,  232 
infraction  of,  233 
Rickets,  75 
Rontgen,  9 
Rubber  adhesive  plaster  in  fracture  of 

rib,  235 
Ruhmkorff  induction  coil,  277,  279 


Salicylic  acid  as  a  mouth-wash,  274 

Saline  infusions,  65 

Sayre's  dressing  for  fracture  of  clavicle, 

86 
Scaphoid,  fracture  of,  231 
Scapula,  fracture  of,  89 
Screen,  fluorescing,  284 
Serothorax,  skiagraphy  in,  290 
Scurvy,  fragility  of  bones  in,  75 
Shock  in  fractures,  26 
Shoulder,  fracture  of,  78 
Signs  of  fracture,  21 
Silicate-of-potassium  dressing,  46 
Simple  fracture,  iS 
Skiagraphic  errors,  31 1 
Skiagraphs,  taking  of,  285 
Skiameter,   283 
Skin-bacteria,  54 
Skin-incision,   danger  of   infection  in, 

57 


Skull,  fracture  of,  247 

Soap  for  sterilization,  55 

Sodium  dressing,  46 

Spasms   in   fracture  of  spinal  column, 

243 
Spina  bifida,  skiagraphy  in,  299 
Spinal  column,  fracture  of,  239 
Spine,  scapular,  fracture  of,  89 
Spinous  process,  vertebral,  fracture  of, 

246 
Spiral  fracture,  18 

infratrochanteric  fracture,  179 
Splinters  in  compound  fractures,  65 

removal  of,  in  fracture  of  skull,  259 
Splints  in  general,  48 

of  fiber,  4S 

of  lime-wood,  48 

of  wire,  48 
Spondylitis,  28S 
Spontaneous  fractures,  17 
Staircase-shaped  exsection,  70 
Stand,  adjustable,  for  skiagraphic  work, 

308 
Static  machine,  277,  309 
Statistics,  20 
Stellate  splinter  fracture  of  the  scapula, 

90  . 

Sterilization,  52 

of  aspirating  needles,  19S 

of  syringes,  199 
Sternum,  fracture  of,  238 
Stomach,  skiagraphy  of,  294 
Storage-battery,  277 
Strabismus  in  fracture  of  base  of  skull, 

267 
Styloid  process  of  ulna,  fracture  of,  1 29 
Subcoracoid  dislocation,  93,  99 
Subcutaneous  fracture,  34 

suture,  58 
Subglenoid  dislocation,  99 
Subphrenic  abscess,  skiagraphy  of,  291 
Superior  maxilla,  fracture  of,  270 
Supramalleolar  fracture,  209 
Suspension  in  a  splint,  45 
Swelling  of  soft  tissues,  27 
Sycosis  treated  by  Rontgen  rays,  301 
Symptoms  of  fracture  in  children,  75 
Syphilis,  288 


Talipes,  287 

Tarsal  bones,  fracture  of,  226 

gangrene  of,  227 
Tesla's  high-tension  induction  coil,  277 
Thigh,  fracture  of,  168 

position  of,  in  skiagraph}',  307 

skiagraphing  the,  308 


INDEX. 


OOD 


Tibia,  appearance  of  nucleus  in,  74 

atrophy  of,  217 

backward  displacement  in  fracture  of, 
222 

epiphyseal  cartilage  of,  320 

error  in  fracture  of,  219 

gunshot  fracture  of,  217 

infraction  of,  219 

isolated  fracture  of,  216 

simultaneous    fracture    of    tibia    and 
fibula,  205 

spiral  fracture  of,  221 
Thrombosis,  32 

Thumb,  dorsal  dislocation  of,  162 
Torsion,  19 
Tracheotomy  in  fracture  of  the  larynx, 

275 
Transposition  of  the  viscera,  293 
Transverse  fracture,  18 
Traumatic  cause  of  gangrene,  32 
Treatment  in  general,  34 

of  disturbances  in  the  process  of  re- 
pair, 70 
Trephining  of  spinal  canal,  245 
Trochanter   major,  isolated  fracture  of, 

177 
Trochlea,   epiphyseal    cartilage  of,  319 
Trunk,  fractures  of  bones  of,  232 
Tube,  capacity  of,  305 

distance  from,  305 
Tuberculosis,  differentiation  of,  268 

of  bones,  fragility  in,  75 
Tubes,  9,  280,  305 

permitting  of  regulation,  305 
Tumors     of     shoulder,     differentiation 

from  fractures,   100 
Tympanum,    laceration   of,   in   fracture 

of  base  of  skull,  266 


Ulna,  epiphyseal  cartilages  of,  321 
fracture  of,  122 

coronoid  process  of,  125 
diaphysis  of,  127 
fissure  of  capitulum  of,  131 
isolated  fracture  of  styloid  process  of, 
129 
Upper  arm,  position  of,  in  skiagraphy, 

306 
Urine  in  fractures,  26 

of  spinal  column,  244 


Vacuum,  height  of  the,  304 
of  Rontgen  tube,  282 

Velpeau*s  dressing  for  fracture  of  clav- 
icle, 85 

Venous  stasis,  39 

Vertebral  bodies,  fracture  of,  239 
infraction  of,  240 

Vertical  extension  in  infantile  fracture 
of  femur,  186 

Vertex,  fracture  of,  248 

Vesical  calculi,  skiagraphy  of,  294 

Vibrator,  279 

Volkmann's  foot-board,  50 


Wire  splints,  48,  67 
Wiring  of  bone-fragments,  51 

in  fracture  of  inferior  maxilla,  273 

of  patella,  201 
Wound-margins,  protection  of,  58 


Zygoma,  fracture  of,  271 


CATALOGUE 

OF   THE 

MEDICAL  PUBLICATIONS 

OF 

W.  B*  SAUNDERS, 

No.   925   WALNUT   STREET,   PHILADELPHIA* 


Arranged  Alphabetically  and  Classified  under  Subjects. 


THE  books  advertised  in  this  Catalogue  as  being  sold  by  subscription  are  usually  to  be 
obtained  from  travelling  solicitors,  but  they  will  be  sent  direct  from  the  office  of  pub- 
lication (charges  of  shipment  prepaid)  upon  receipt  of  the  prices  given.     All  the  other 
books  advertised  are  commonly  for  sale  by  booksellers  in  all  parts  of  the  United  States ;  but 
books  will  be  sent  to  any  address,  carriage  prepaid,  on  receipt  of  the  published  price. 

Money  may  be  sent  at  the  risk  of  the  publisher  in  either  of  the  following  ways :  A  post- 
office  money  order,  an  express  money  order,  a  bank  check,  and  in  a  registered  letter.  Money 
sent  in  any  other  way  is  at  the  risk  of  the  sender. 


See  pages  32,  33  for  a  List  of  Contents  classified  according  to  subjects. 


LATEST  PUBLICATIONS. 


International  Text-Book  of  Surgery.     See  page  15. 

American  Text-Book  of  Surgery — Third  (Revised)  Edition.    See  page  7. 

American  Text-Book  of  Dis.  of  Eye,  Ear,  Nose,  and  Throat.     Page  5. 

American  Text-Book  of  Genito-Urinary  and  Skin  Diseases.     Page  6. 

Saunders'  American  Year-Book  for  1900.     See  page  8. 

Levy  and  Klemperer's  Clinical  Bacteriology.     See  page  17. 

Scudder's  Treatment  of  Fractures.     See  page  26. 

Beck  on  Fractures.     See  page  9. 

Heisler's  Embryology.     See  page  15. 

Nancrede's  Principles  of  Surgery.     See  page  20. 

Jackson's  Diseases  of  the  Eye.     See  page  16. 

Kyle  on  the  Nose  and  Throat.     See  page  17. 

Pryor's  Pelvic  Inflammations.     See  page  2J. 

Abbott's  Hygiene  of  Transmissible  Diseases.     See  page  8. 

Stengel's  Text-Book  of  Pathology — Second  Edition.     See  page  28. 

Hirst's  Text-Book  of  Obstetrics — Second  Edition.     See  page  15. 

Penrose's  Diseases  of  Women — Third  (Revised)  Edition.     Page  20. 

Warren's  Surgical  Pathology — Second  (Revised)  Edition.     Page  31. 

Anders'  Practice  of  Medicine — Third  I  Revised  I  Edition.     See  page  8. 

Church  and  Peterson's  Nervous  and  Mental  Diseases — 2d  Ed.     Page  10. 

Da  Costa's  Surgery — Revised  and  Enlarged  Edition.     See  page  12. 

Saunders'  Medical  Hand-Atlases.     See  pages  2,  3,  4. 

De Schweinitz's  Diseases  of  the  Eye — Third  (Revised)  Ed.     Page  12. 

American  Pocket  Medical  Dictionary — Second  i  Revised)  Ed.     Page  12. 


SAUNDERS' 

MEDICAL  HAND-ATLASES. 


The  series  of  books  included  under  this  title  consists  of  authorized 
translations  into  English  of  the  world-famous  Lehmann  Medicinische 
Handatlanten,  which  for  scientific  accuracy,  pictorial  beauty,  com- 
pactness, and  cheapness  surpass  any  similar  volumes  ever  published. 
Each  volume  contains  from  50  to  100  colored  plates,  executed  by  the 
most  skilful  German  lithographers,  besides  numerous  illustrations  in  the 
text.  There  is  a  full  and  appropriate  description  of  each  plate,  and 
each  book  contains  a  condensed  but  adequate  outline  of  the  subject  to 
which  it  is  devoted. 

One  of  the  most  valuable  features  of  these  atlases  is  that  they  offer  a 
ready  and  satisfactory  substitute  for  clinical  observation.  To  those 
unable  to  attend  important  clinics  these  books  will  be  absolutely  indis- 
pensable. 

In  planning  this  series  of  books  arrangements  were  made  with  the  rep- 
resentative publishers  in  the  chief  medical  centers  of  the  world  for  the 
publication  of  translations  of  the  atlases  into  different  languages,  the  litho- 
graphic plates  for  all  these  editions  being  made  in  Germany,  where  work  of 
this  kind  has  been  brought  to  the  greatest  perfection.  The  expense  of 
making  the  plates  being  shared  by  the  various  publishers,  the  cost  to  each 
one  was  materially  reduced.  Thus  by  reason  of  their  universal  transla- 
tion and  reproduction,  the  publishers  have  been  enabled  to  secure  for  these 
atlases  the  best  artistic  and  professional  talent,  to  produce  them  in  the 
most  elegant  style,  and  yet  to  offer  them  at  a  price  heretofore  unap- 
proached  in  cheapness.  The  success  of  the  undertaking  is  demonstrated 
by  the  fact  that  the  volumes  have  already  appeared  in  thirteen  different 
languages — German,  English,  French,  Italian,  Russian,  Spanish,  Japanese, 
Dutch,  Danish,  Swedish,  Roumanian,  Bohemian,  and  Hungarian. 

In  view  of  the  striking  success  of  these  works,  Mr.  Saunders  has  con- 
tracted with  the  publisher  of  the  original  German  edition  for  one  hun- 
dred thousand  copies  of  the  atlases.  In  consideration  of  this  enormous 
undertaking,  the  publisher  has  been  enabled  to  prepare  and  furnish  special 
additional  colored  plates,  making  the  series  even  handsomer  and  more 
complete  than  was  originally  intended. 

As  an  indication  of  the  practical  value  of  the  atlases  and  of  the  favor 
with  which  they  have  been  received,  it  should  be  noted  that  the  Medical 
Department  of  the  U.S.  Army  has  adopted  the  "Atlas  of  Operative 
Surgery"  as  its  standard,  and  has  ordered  the  book  in  large  quantities  for 
distribution  to  the  various  regiments  and  army  posts. 

The  same  careful  and  competent  editorial  supervision  has  been 
secured  in  the  English  edition  as  in  the  originals,  the  translations  being 
edited  by  the  leading  American  specialists  in  the  different  subjects. 


SAUNDERS'  MEDICAL  HAND-ATLASES. 


VOLUMES  NOW  READY. 
Atlas  and   Epitome  of    Internal  Medicine  and    Clinical    Diagnosis. 

By  Dr.  Chr.  Jakob,  ofErlangen.  Edited  by  Augustus  A.  Eshner,  M.D., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  68  colored 
plates,  64  text-illustrations,  and  259  pages  of  text.     Cloth,  $3.00  net. 

"  The  charm  of  the  book  is  its  clearness,  conciseness,  and  the  accuracy  and  beauty  of  its 
illustrations.  It  deals  with  facts.  It  vividly  illustrates  those  facts.  It  is  a  scientific  work 
put  together  for  ready  reference." — Brooklyn  Medical  Journal. 

Atlas  of  Legal  Medicine.    By  Dr.  E.  R.  von  Hofmann,  of  Vienna.    Edited 

by  Frederick  Peterson,  M.D.,  Chief  of  Clinic,  Nervous  Dept.,  College 

of  Physicians  and  Surgeons,  New  York.    With  120  Colored  figures  on  56 

plates,  and  193  beautiful  half-tone  illustrations.      Cloth,  $3.50  net. 

"  Hofmann's  'Atlas  of  Legal  Medicine  '  is  a  unique  work.    This  immense  field  finds  in  this 

book  a  pictorial  presentation  that  far  excels  anything  with  which  we  are  familiar  in  any  other 

work." — Philadelphia  Medical  Journal. 

Atlas  and  Epitome  of  Diseases  of  the  Larynx.  By  Dr.  L.  Grunwald, 
of  Munich.  Edited  by  Charles  P.  Grayson,  M.D.,  Physician-in-Charge, 
Throat  and  Nose  Department,  Hospital  of  the  University  of  Pennsylvania. 
With  107  colored  figures  on  44  plates,  25  text- illustrations,  and  103  pages 
of  text.     Cloth,  $2.50  net. 

"  Aided  as  it  is  by  magnificently  executed  illustrations  in  color,  it  cannot  fail  of  being  of 
the  greatest  advantage  to  students,  general  practitioners,  and  expert  laryngologists." — St. 
Louis  Medical  and  Surgical  Journal. 

Atlas  and  Epitome  of  Operative  Surgery.  By  Dr.  O.  Zuckerkandl, 
of  Vienna.  Edited  by  J.  Chalmers  DaCosta,  M.D.,  Clinical  Professor 
of  Surgery,  Jefferson  Medical  College,  Philadelphia.  With  24  colored 
plates,  217  text-illustrations,  and  395  pages  of  text.      Cloth,  $3.00  net. 

"  We  know  of  no  other  work  that  combines  such  a  wealth  of  beautiful  illustrations  with 
clearness  and  conciseness  of  language,  that  is  so  entirely  abreast  of  the  latest  achievements, 
and  so  useful  both  for  the  beginner  and  for  one  who  wishes  to  increase  his  knowledge  of 
operative  surgery." — Munchener  medicinische  Wochenschrift. 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Diseases.  By  Prof. 
Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton  Bangs,  M.D., 
Professor  of  Genito-Urinary  Surgery,  University  and  Bellevue  Hospital 
Medical  College,  New  York.  With  71  colored  plates,  16  black-and- 
white  illustrations,  and  122  pages  of  text.      Cloth,  $3.50  net. 

"  A  glance  through  the  book  is  almost  like  actual  attendance  upon  a  famous  clinic." — 
Journal  of  the  American  Medical  Association. 

Atlas   and    Epitome  of  External  Diseases  of  the  Eye.     By  Dr.  O. 

Haab,  of  Zurich.  Edited  by  G.  E.  de  Schweinitz,  M.D.,  Professor  of 
Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With  76 
colored  illustrations  on  40  plates,  and  228  pages  of  text.    Cloth,  $3.00  net. 

"  It  is  always  difficult  to  represent  pathological  appearances  in  colored  plates,  but  this 
work  seems  to  have  overcome  these  difficulties,  and  the  plates,  with  one  or  two  exceptions, 
are  absolutely  satisfactory." — Boston  Medical  and  Surgical  Journal. 

Atlas  and  Epitome  of  Skin  Diseases.  By  Prof.  Dr.  Franz  Mracek, 
of  Vienna.  Edited  by  Henry  W.  Stelwagon,  M.D.,  Clinical  Professor 
of  Dermatology,  Jefferson  Medical  College,  Philadelphia.  With  63  colored 
plates,  39  half-tone  illustrations,  and  200  pages  of  text.    Cloth,  $3.50  net. 

"  The  importance  of  personal  inspection  of  cases  in  the  study  of  cutaneous  diseases  is 
readily  appreciated,  and  next  to  the  living  subjects  are  pictures  which  will  show  the  appear- 
ance of  the  disease  under  consideration.  Altogether  the  work  will  be  found  of  very  great 
value  to  the  general  practitioner." — Journal  of  the  American  Medical  Association. 

3 


SAUNDERS'  MEDICAL  HAND-ATLASES. 


IN  PRESS  FOR  EARLY  PUBLICATION. 
Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.     By  Dr.  Ed. 

Golebiewski,  of  Berlin.  Translated  and  edited  with  additions  by 
Pearce  Bailey,  M.D.,  Attending  Physician  to  the  Department  of  Cor- 
rections and  to  the  Almshouse  and  Incurable  Hospitals,  New  York. 
With  40  colored  plates,  143  text-illustrations,  and  600  pages  of  text. 

Atlas  and  Epitome  of  Special  Pathological  Histology.  By  Dr.  H. 
Durck,  of  Munich.  Edited  by  Ludvig  Hektoen,  M.D.,  Professor  of 
Pathology,  Rush  Medical  College,  Chicago.  Two  volumes,  with  about 
120  colored  plates,  numerous  text-illustrations,  and  copious  text. 

Atlas  and   Epitome   of   General    Pathological    Histology.     With   an 

Appendix  on  Pathohistological  Technic.  By  Dr.  H.  Durck,  of 
Munich.  Edited  by  Ludvig  Hektoen,  M.D.,  Professor  of  Path- 
ology, Rush  Medical  College,  Chicago.  With  80  colored  plates, 
numerous  text-illustrations,  and  copious  text. 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of  Heidel- 
berg. Edited  by  Richard  C.  Norris,  A.M.,  M.D.,  Gynecologist  to 
the  Methodist  Episcopal  and  the  Philadelphia  Hospitals ;  Surgeon-in- 
Charge  of  Preston  Retreat,  Philadelphia.  With  90  colored  plates,  65 
text-illustrations,  and  308  pages  of  text. 

IN  PREPARATION. 
Atlas  and  Epitome  of  Orthopedic  Surgery.     By  Dr.  Schultess  and 
Dr.  Luning,  of  Zurich,     With  about  100  colored  illustrations. 

Atlas  and  Epitome  of  Operative  Gynecology.  By  Dr.  O.  Schaffer, 
of  Heidelberg.  With  40  colored  plates  and  numerous  illustrations  in 
black-and-white  from  original  paintings. 

Atlas  and  Epitome  of  Diseases  of  the  Ear.  Edited  by  Prof.  Dr. 
Politzer,  of  Vienna,  and  Dr.  G.  Bruhl,  of  Berlin.  With  120  colored 
illustrations  and  about  200  pages  of  text. 

Atlas  and  Epitome  of  General  Surgery.  Edited  by  Dr.  Marwedel, 
with  the  cooperation  of  Prof.  Dr.  Czerny.  With  about  200  colored 
illustrations. 

Atlas  and  Epitome  of  Psychiatry.  By  Dr.  Wilh.  Weygandt,  of 
Wiirzburg.     With  about   120  colored  illustrations. 

Atlas  and  Epitome  of  Normal  Histology.    By  Dr.  Johannes  Sobotta, 

of  Wiirzburg.      With   80  colored   plates  and   numerous  illustrations  in 

the  text. 
Atlas   and    Epitome    of    Topographical    Anatomy.       By    Prof.    Dr. 

Schultzf,  of  Wiirzburg.      With  about  100  colored  illustrations  and  a 

very  copious  text. 


THE  AMERICAN  TEXT-BOOK  SERIES. 

AN  AMERICAN  TEXT=BOOK  OF  APPLIED  THERAPEUTICS. 

By  43  Distinguished  Practitioners  and  Teachers.  Edited  by  James  C. 
Wilson,  M.D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical 
Medicine  in  the  Jefferson  Medical  College,  Philadelphia.  One  hand- 
some imperial  octavo  volume  of  1326  pages.  Illustrated.  Cloth, 
#7.00  net;  Sheep  or  Half  Morocco,  $8.00  net.     Sold  by  Subscription. 

"  As  a  work  either  for  study  or  reference  it  will  be  of  great  value  to  the  practitioner,  as 
it  is  virtually  an  exposition  of  such  clinical  therapeutics  as  experience  has  taught  to  be  of 
the  most  value.  Taking  it  all  in  all,  no  recent  publication  on  therapeutics  can  be  compared 
with  this  one  in  practical  value  to  the  working  physician." — Chicago  Clinical  Review. 

"The  whole  field  of  medicine  has  been  well  covered.  The  work  is  thoroughly  prac- 
tical, and  while  it  is  intended  for  practitioners  and  students,  it  is  a  better  book  for  the  general 
practitioner  than  for  the  student.  The  young  practitioner  especially  will  find  it  extremely 
suggestive  and  helpful." — The  Indian  Lancet. 

AN  AMERICAN  TEXT=BOOK  OF  THE  DISEASES  OF  CHILDREN. 
Second  Edition,  Revised. 

By  65  Eminent  Contributors.  Edited  by  Louis  Starr.  M.  D.,  Con- 
sulting Pediatrist  to  the  Maternity  Hospital,  etc.  ;  assisted  by  Thomp- 
son S.  Westcott,  M.  D.,  Attending  Physician  to  the  Dispensary 
for  Diseases  of  Children,  Hospital  of  the  University  of  Pennsyl- 
vania. In  one  handsome  imperial  octavo  volume  of  1244  pages, 
profusely  illustrated.  Cloth,  $7.00  net;  Sheep  or  Half  Morocco, 
$8.00  net.     Sold  by  Subscription. 

"This  is  far  and  away  the  best  text-book  on  children's  diseases  ever  published  in  the 
English  language,  and  is  certainly  the  one  which  is  best  adapted  to  American  readers. 
We  congratulate  the  editor  upon  the  result  of  his  work,  and  heartily  commend  it  to  the 
attention  of  every  student  and  practitioner." — American  Journal  of  the  Medical  Sciences. 

AN  AMERICAN  TEXT=BOOK  OF  DISEASES  OF  THE  EYE,  EAR, 
NOSE,  AND  THROAT. 

By  58  Prominent  Specialists.  Edited  by  G.  E.  de  Schweinitz,  M.D  , 
Professor  of  Ophthalmology  in  the  Jefferson  Medical  College,  Phila- 
delphia ;  and  B.  Alexander  Randall,  M.D.,  Professor  of  Diseases 
of  the  Ear  in  the  University  of  Pennsylvania.  Imperial  octavo,  1251 
pages;  766  illustrations,  59  of  them  in  colors.  Cloth,  $7.00  net;  Sheep 
or  Half  Morocco,  $8.00  net.     Sold  by  Subscription. 

Illustrated  Catalogue  of  the  "American  Text-Books"  sent  free  upon  application. 


6  Medical  Publications  of  W.  B.  Saunders. 

AN  AMERICAN   TEXT=BOOK   OF   GENITOURINARY  AND  SKIN 
DISEASES. 

By  47  Eminent  Specialists  and  Teachers.  Edited  by  L.  Bolton 
Bangs,  M.  D.,  Professor  of  Genito- Urinary  Surgery,  University  and 
Bellevue  Hospital  Medical  College,  New  York ;  and  W.  A.  Hard- 
away,  M.  D.,  Professor  of  Diseases  of  the  Skin,  Missouri  Medical 
College.  Imperial  octavo  volume  of  1229  pages,  with  300  engravings 
and  20  full-page  colored  plates.  Cloth,  $7.00  net;  Sheep  or  Half 
Morocco,  $8.00  net.     Sold  by  Subscription. 

"  This  volume  is  one  of  the  best  yet  issued  of  the  publisher's  series  of '  American  Text- 
Books.'  The  list  of  contributors  represents  an  extraordinary  array  of  talent  and  extended 
experience.  The  book  will  easily  take  the  place  in  comprehensiveness  and  value  of  the 
half  dozen  or  more  costly  works  on  these  subjects  which  have  heretofore  been  necessary  to 
a  well-equipped  library." — New  York  Polyclinic. 

AN  AMERICAN  TEXT=BOOK  OF  GYNECOLOGY,  MEDICAL  AND 
SURGICAL.     Second  Edition,  Revised. 

By  10  of  the  Leading  Gynecologists  of  America.     Edited  by  J.   M. 
Baldy,  M.  D.,  Professor  of  Gynecology  in  the  Philadelphia  Polyclinic, 
etc.     Handsome  imperial  octavo  volume  of  718  pages,  with  341  illus- 
trations in  the  text,  and  38  colored  and  half-tone  plates.     Cloth,  $6.00 
net;  Sheep  or  Half  Morocco,  $7.00  net.     Sold  by  Subscription. 
"  It  is  practical  from  beginning  to  end.     Its  descriptions  of  conditions,  its  recommen- 
dations for  treatment,  and  above  all  the  necessary  technique  of  different  operations,  are 
clearly  and  admirably  presented.     .     .     .     It  is  well  up  to  the  most  advanced  views  of  the 
day,  and  embodies  all  the  essential  points  of  advanced  American  gynecology.     It  is  destined 
to  make  and  hold  a  place  in  gynecological   literature  which  will  be  peculiarly  its  own." — 
Medical  Record,  New  York. 

AN  AMERICAN  TEXT-BOOK  OF  LEGAL  MEDICINE  AND  TOXI- 
COLOGY. 

Edited  by  Frederick  Peterson,  M.D.,  Clinical  Professor  of  Mental 
Diseases  in  the  Woman's  Medical  College,  New  York;  Chief  of  Clinic, 
Nervous  Department,  College  of  Physicians  and  Surgeons,  New  York ; 
and  Walter  S.  Haines,  M.D.,  Professor  of  Chemistry,  Pharmacy, 
and  Toxicology  in  Rush  Medical  College,  Chicago.     In  Preparation. 

AN  AMERICAN  TEXT=BOOK  OF  OBSTETRICS. 

By  15  Eminent  American  Obstetricians.  Edited  by  Richard  C.  Nor- 
ris,  M.D.;  Art  Editor,  Robert  L.  Dickinson,  M.D.  One  handsome 
imperial  octavo  volume  of  1014  pages,  with  nearly  900  beautiful  colored 
and  half-tone  illustrations.  Cloth,  $7.00  net;  Sheep  or  Half  Morocco, 
$8.00  net.     Sold  by  Subscription. 

"  Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  I  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work, 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers." — Alexander 
J.  C.  Skene,  Professor  of  Gynecology  in  the  Long  Island  College  Hospital,  Brooklyn,  N.  Y. 

"  This  is  the  most  sumptuously  illustrated  work  on  midwifery  that  has  yet  appeared.  la 
the  number,  the  excellence,  and  the  beauty  of  production  of  the  illustrations  it  far  surpasses 
every  other  book  upon  the  subject.  This  feature  alone  makes  it  a  work  which  no  medical 
library  should  omit  to  purchase." — British  Medical  Journal. 

"  A&  an  authority,  as  a  book  of  reference,  as  a  '  working  book  '  for  the  student  or  prac- 
titioner, we  commend  it  because  we  believe  there  is  no  better." — American  Journal  of  the 
Medical  Sciences. 

Illustrated  Catalogue  of  the  "American  Text-Books  "  sent  free  upon  application. 


Medical  Publications  of  W.  B.  Saunders. 

AN  AMERICAN  TEXT=BOOK  OF  PATHOLOGY. 

Edited  by  Ludvig  Hektoen,  M.  D..  Professor  of  General  Pathology 
and  of  Morbid  Anatomy  in  the  University  of  Pennsylvania;  and 
David  Riesman,  M.  D.,  Demonstrator  of  Pathological  Histology  in 
the  University  of  Pennsylvania.     In  preparation. 

AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY. 

By  10  of  the  Leading  Physiologists  of  America.  Edited  by  William 
H.  Howell,  Ph.D.,  M.D.,  Professor  of  Physiology  in  the  Johns  Hop- 
kins University,  Baltimore,  Md.  One  handsome  imperial  octavo 
volume  of  1052  pages.  Illustrated.  Cloth,  $6.00  net ;  Sheep  or  Half 
Morocco,  $7. 00  net.     Sold  by  Subscription. 

"  We  can  commend  it  most  heartily,  not  only  to  all  students  of  physiology,  but  to  every 
physician  and  pathologist,  as  a  valuable  and  comprehensive  work  of  reference,  written  by 
men  who  are  of  eminent  authority  in  their  own  special  subjects." — London  Lancet. 

"  To  the  practitioner  of  medicine  and  to  the  advanced  student  this  volume  constitutes, 
we  believe,  the  best  exposition  of  the  present  status  of  the  science  of  physiology  in  the 
English  language." — American  Journal  of  the  Medical  Sciences. 

AN   AMERICAN   TEXT=BOOK   OF   SURGERY.     Third  Edition. 

By  n  Eminent  Professors  of  Surgery.     Edited  by  William  W.  Keen, 
M.D.,  LL.D.,  and  J.  William  White,  M.D.,  Ph.D.     Handsome  im- 
perial octavo  volume  of  1230  pages,  with  496  wood-cuts  in  the  text, 
and  37  colored  and  half-tone  plates.     Thoroughly  revised  and  enlarged, 
with  a  section  devoted  to  "  The  Use  of  the  Rontgen  Rays  in  Surgery." 
Cloth,  $7.00  net;  Sheep  or  Half  Morocco,  $8.00  net. 
«'  Personally,  I  should  not  mind  it  being  called  THE  Text-Book  (instead  of  A  Text- 
Book),  for  I  know  of  no  single  volume  which  contains  so  readable  and  complete  an  account 
of  the  science  and  art  of  Surgery  as  this  does." — Edmund  Owen,  F.R.C.S.,  Member  of 
the  Board  of  Examiners  of  the  Royat  College  of  Surgeons,  England. 

"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 
London  Lancet. 

AN  AMERICAN  TEXT=BOOK  OF  THE  THEORY  AND  PRACTICE 
OF  MEDICINE. 

By  12  Distinguished  American  Practitioners.  Edited  by  William 
Pepper,  M.D.,  LL.D.,  Professor  of  the  Theory  and  Practice  of  Medi- 
cine and  of  Clinical  Medicine  in  the  University  of  Pennsylvania.  Two 
handsome  imperial  octavo  volumes  of  about  1000  pages  each.  Illus- 
trated. Prices  per  volume  :  Cloth,  $5.00  net ;  Sheep  or  Half  Morocco, 
$6.00  net.     Sold  by  Subscription. 

"  I  am  quite  sure  it  will  commend  itself  both  to  practitioners  and  students  of  medicine, 
and  become  one  of  our  most  popular  text-books." — Alfred  Loomis,  M.D.,  LL.D.,  Pro- 
fessor of  Pathology  and  Practice  of  Medicine,  University  of  the  City  of  New  York. 

"  We  reviewed  the  first  volume  of  this  work,  and  said  :  '  It  is  undoubtedly  one  of  the 
best  text-books  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the 
second  and  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work 
is  in  our  opinion  the  best  of  its  kind  it  has  ever  been  our  fortune  to  see." — New  York  Medical 
Journal. 

Illustrated  Catalogue  of  the  "  American  Text-Books"  sent  free  upon  application. 


8  Medical  Publications  of  W.  B.  Saunders. 

AN  AMERICAN  YEAR-BOOK  OF  MEDICINE  AND  SURGERY. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  Foreign  authors  and 
investigators.  Arranged  with  critical  editorial  comments,  by  eminent 
American  specialists,  under  the  general  editorial  charge  of  George  M. 
Gould,  M.D.  Volumes  for  1896,' '97,  '98,  and  '99.  One  imperial 
octavo  volume  of  about  1200  pages.  Cloth,  $6.50  net ;  Half  Morocco, 
$7.50  net.  Year-Book  of  1900  in  two  volumes — Vol.  I.,  including 
General  Medicine;  Vol.  II.,  General  Surgery.  Prices  per  volume: 
Cloth,  $3.00  net;   Half  Morocco,  $3.75  net.     Sold  by  Subscription. 

"  It  is  difficult  to  know  which  to  admire  most — the  research  and  industry  of  the  distin- 
guished band  of  experts  whom  Dr.  Gould  has  enlisted  in  the  service  of  the  Year- Book,  or  the 
wealth  and  abundance  of  the  contributions  to  every  department  of  science  that  have  been 
deemed  worthy  of  analysis.  ...  It  is  much  more  than  a  mere  compilation  of  abstracts,  for, 
as  each  section  is  entrusted  to  experienced  and  able  contributors,  the  reader  has  the  advant- 
age of  certain  critical  commentaries  and  expositions  .  .  .  proceeding  from  writers  fully 
qualified  to  perform  these  tasks.  ...  It  is  emphatically  a  book  which  should  find  a  place  in 
every  medical  library,  and  is  in  several  respects  more  useful  than  the  famous  '  Jahrbiicher' 
of  Germany." — London  Lancet. 

ABBOTT  ON  TRANSMISSIBLE  DISEASES. 

The  Hygiene  of  Transmissible  Diseases ;  their  Causation, 
Modes   of    Dissemination,  and  Methods  of  Prevention.     By  A. 

C.  Abbott,  M.D.,  Professor  of  Hygiene  and  Bacteriology,  University 
of  Pennsylvania ;  Director  of  the  Laboratory  of  Hygiene.  Octavo 
volume  of  311  pages,  containing  a  number  of  charts  and  maps,  and 
numerous  illustrations.      Cloth,  $2.00  net. 

THE  AMERICAN  POCKET  MEDICAL  DICTIONARY. 

[See  D  or  I  and' s  Pocket  Dictionary,  page  12.  J 

ANDERS'  PRACTICE  OF  MEDICINE.  Third  Revised  Edition. 
A  Text-Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  In  one 
handsome  octavo  volume  of  1292  pages,  fully  illustrated.  Cloth, 
#5.50  net;  Sheep  or  Half  Morocco,  $6.50  net. 

"  It  is  an  excellent  book, — concise,  comprehensive,  thorough,  and  up  to  date.  It  is  a 
credit  to  you  ;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia — to  us." 
James  C.  Wilson,  Professor  of  the  Practice  of  Medicine  and  Clinical  Medicine,  Jefferson 
Medical  College,  Philadelphia. 

ASHTON'S  OBSTETRICS.     Fourth  Edition,  Revised. 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D.,  Pro. 
fessor  of  Gynecology  in  the  Medico-Chirurgical  College,  Philadelphia. 
Crown  octavo,  252  pages  ;  75  illustrations.  Cloth,  $1. 00;  interleaved 
for  notes,  $1.25. 

[See  Saunders'  Question- Com/ends,  page  23.] 

"  Embodies  the  whole  subject  in  a  nutshell.  We  cordially  recommend  it  to  our  read- 
ers."— Chicago  Medical  Times. 


Medical  Publications  of  W.  B.  Saunders.  9 

BALL'S  BACTERIOLOGY.     Third  Edition,  Revised. 

Essentials  of  Bacteriology  ;  a  Concise  and  Systematic  Introduction 
to  the  Study  of  Micro-organisms.  By  M.  V.  Ball,  M.D.,  Bacteriol- 
ogist to  St.  Agnes'  Hospital,  Philadelphia,  etc.  Crown  octavo,  218 
pages;  82  illustrations,  some  in  colors,  and  5  plates.  Cloth,  $1.00; 
interleaved  for  notes,  $1.25. 

[See  Saunders'  Question-  Compends,  page   23.] 

"  The  student  or  practitioner  can  readily  obtain  a  knowledge  of  the  subject  from  a  perusal 
of  this  book.     The  illustrations  are  clear  and  satisfactory." — Medical  Record,  New  York. 

BASTIN'S  BOTANY. 

Laboratory  Exercises  in  Botany.  By  Edson  S.  Bastin,  M.A., 
late  Professor  of  Materia  Medica  and  Botany,  Philadelphia  College  of 
Pharmacy.    Octavo  volume  of  536  pages,  with  87  plates.    Cloth,  $2.50. 

"It  is  unquestionably  the  best  text-book  on  the  subject  that  has  yet  appeared.  The 
work  is  eminently  a  practical  one.  We  regard  the  issuance  of  this  book  as  an  important 
event  in  the  history  of  pharmaceutical  teaching  in  this  country,  and  predict  for  it  an  unquali- 
fied success." — Alumni  Report  to  the  Philadelphia  College  of  Pharmacy. 

BECK  ON  FRACTURES. 

Fractures.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's  Hospital 
and' the  New  York  German  Poliklinik,  etc.  225  pages,  170  illustrations. 
Cloth,  $  net. 

BECK'S  SURGICAL  ASEPSIS. 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.D.,  Surgeon  to 
St.  Mark's  Hospital  and  the  New  York  German  Poliklinik,  etc.  306 
pages;  65  text-illustrations,  and  1 2  full-page  plates.     Cloth,  $  1.2 5  net. 

"  An  excellent  exposition  of  the  '  very  latest '  in  the  treatment  of  wounds  as  practised 
by  leading  German  and  American  surgeons." — Birmingham  (Eng.)  Medical  Review. 

"  This  little  volume  can  be  recommended  to  any  who  are  desirous  of  learning  the  details 
of  asepsis  in  surgery,  for  it  will  serve  as  a  trustworthy  guide." — London  Lancet. 

BOISLINIERE'S  OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND 
OPERATIONS. 
Obstetric  Accidents,  Emergencies,  and  Operations.     By  L.  Ch. 

Boisliniere,  M.D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis 
Medical  College.    381  pages,  handsomely  illustrated.    Cloth,  $2.00  net. 

"  A  manual  so  useful  to  the  student  or  the  general  practitioner  has  not  been  brought  to 
our  notice  in  a  long  time.  The  field  embraced  in  the  title  is  covered  in  a  terse,  interesting 
way." —  Yale  Medical  Journal. 

BROCKWAY'S  MEDICAL  PHYSICS.     Second  Edition,  Revised. 
Essentials  of   Medical   Physics.     By  Fred  J.  Brockway,  M.D., 
Assistant  Demonstrator  of  Anatomy  in  the  College  of  Physicians  and 
Surgeons,  New  York.     Crown  octavo,  330  pages;   155  fine  illustrations. 
Cloth,  $1.00  net ;  interleaved  for  notes,  $1.25  net. 

[See  Saunders''  Question- Compends,  page   23.] 

"We  know  of  no  manual  that  affords  the  medical  student  a  better  or  more  concise 
exposition  of  physics,  and  the  book  may  be  commended  as  a  most  satisfactory  presentation 
of  those  essentials  that  are  requisite  in  a  course  in  medicine." — New  York  Medical  Journal. 


10  Medical  Publications  of  W.  B.  Saunders. 

BUTLER'S  MATERIA  MEDICA,  THERAPEUTICS,  AND  PHAR- 
MACOLOGY. Third  Edition,  Revised. 
A  Text=Book  of  Materia  Medica,  Therapeutics,  and  Pharma- 
cology. By  George  F.  Butler,  Ph.G.,  M.D.,  Professor  of  Materia 
Medica  and  of  Clinical  Medicine  in  the  College  of  Physicians  and 
Surgeons,  Chicago;  Professor  of  Materia  Medica  and  Therapeutics, 
Northwestern  University,  Woman's  Medical  School,  etc.  Octavo,  874 
pages,  illustrated.     Cloth,  $4.00  net;    Sheep,  $5.00  net. 

"  Taken  as  a  whole,  the  book  may  fairly  be  considered  as  one  of  the  most  satisfactory 
of  any  single-volume  works  on  materia  medica  in  the  market," — Journal  of  the  American 
Medical  Association. 

CERNA  ON  THE  NEWER  REMEDIES.  Second  Edition,  Revised. 
Notes  on  the  Newer  Remedies,  their  Therapeutic  Applications 
and  Modes  of  Administration.  By  David  Cerna,  M.D.,  Ph.D., 
formerly  Demonstrator  of  and  Lecture-r  on  Experimental  Therapeutics 
in  the  University  of  Pennsylvania  ;  Demonstrator  of  Physiology  in  the 
Medical  Department  of  the  University  of  Texas.  Rewritten  and 
greatly  enlarged.     Post-octavo,   253  pages.     Cloth,  #1.25. 

"  The  appearance  of  this  new  edition  of  Dr.  Cerna's  very  valuable  work  shows  that  it 
is  properly  appreciated.  The  book  ought  to  be  in  the  possession  of  every  practising  physi- 
cian."— -New  York  Medical  Journal. 

CHAPIN  ON  INSANITY. 

A  Compendium  of  Insanity.     By  John  B.  Chapin,  M.D.,  LL.D., 

Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane ;  late  Physi- 
cian-Superintendent of  the  Willard  State  Hospital,  New  York ;  Hon- 
orary Member  of  the  Medico-Psychological  Society  of  Great  Britain, 
of  the  Society  of  Mental  Medicine  of  Belgium.  i2ino,  234  pages, 
illustrated.     Cloth,  $1.25  net. 

"  The  practical  parts  of  Dr.  Chapin's  book  are  what  constitute  its  distinctive  merit.  We 
desire  especially  to  call  attention  to  the  fact  that  on  the  subject  of  therapeutics  of  insanity 
the  work  is  exceedingly  valuable.  It  is  not  a  made  book,  but  a  genuine  condensed  thesis, 
which  has  all  the  value  of  ripe  opinion  and  all  the  charm  of  a  vigorous  and  natural  style." — 
Philadelphia  Medical  Journal. 

CHAPMAN'S  MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 
Second  Edition,  Revised. 
Medical  Jurisprudence  and  Toxicology.  By  Henry  C.  Chapman, 
M.D.,  Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence 
in  the  Jefferson  Medical  College  of  Philadelphia.  254  pages,  with  55 
illustrations  and  3  full-page  plates  in  colors.     Cloth,  $1.50  net. 

"The  best  book  of  its  class  for  the  undergraduate  that  we  know  of." — New  York 
Medical  Times. 

CHURCH  AND  PETERSON'S  NERVOUS  AND  MENTAL  DISEASES. 
Second  Edition. 
~  Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.  D., 
Professor  of  Clinical  Neurology,  Mental  Diseases,  and  Medical  Juris- 
prudence in  the  Northwestern  University  Medical  School,  Chicago  ; 
and  Frederick  Peterson,  M.  D.,  Clinical  Professor  of  Mental  Dis- 
eases, Woman's  Medical  College,  N.  Y.  ;  Chief  of  Clinic,  Nervous 
Dept.,  College  of  Physicians  and  Surgeons,  N.  Y.  Handsome  octavo 
volume  of  843  pages,  profusely  illustrated.  Cloth,  #5.00  net;  Half 
Morocco,  $6.00  net. 


Medical  Publications  of  W.  B.  Saunders.  H 

CLARKSON'S  HISTOLOGY. 

A   Text=Book    of    Histology,    Descriptive   and    Practical.      By 

Arthur  Clarkson,  M.B.,  CM.  Edin.,  formerly  Demonstrator  of 
Physiology  in  the  Owen's  College,  Manchester;  late  Demonstrator  of 
Physiology  in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages; 
22  engravings  in  the  text,  and  174  beautifully  colored  original  illustra- 
tions.     Cloth,  strongly  bound,  $4.00  net. 

"  The  work  must  be  considered  a  valuable  addition  to  the  list  of  available  text- books, 
and  is  to  be  highly  recommended." — New  York  Medical  Journal. 

"This  is  one  of  the  best  works  for  students  we  have  ever  noticed.  We  predict  that  the 
book  will  attain  a  well-deserved  popularity  among  our  students." — Chicago  Medical  Recorder. 

CLIMATOLOGY. 

Transactions  of  the  Eighth  Annual  Meeting  of  the  American 
Climatological  Association,  held  in  Washington,  September  22-25, 
1891.  Forming  a  handsome  octavo  volume  of  276  pages,  uniform  with 
remainder  of  series.      (A  limited  quantity  only.)     Cloth,  $1.50. 

COHEN  AND  ESHNER'S  DIAGNOSIS.  Second  Edition,  Revised. 
Essentials  of  Diagnosis.  By  Solomon  Solis-Cohen,  M.D.,  Pro- 
fessor of  Clinical  Medicine  and  Applied  Therapeutics  in  the  Philadel- 
phia Polyclinic  ;  and  Augustus  A.  Eshner,  M.D.,  Professor  of  Clinical 
Medicine  in  the  Philadelphia  Polyclinic.  Post-octavo,  417  pages;  55 
illustrations.     Cloth,  $1.00  net. 

[See  Saunders'  Question- Compends,  page   23.] 

"  We  can  heartily  commend  the  book  to  all  those  who  contemplate  purchasing  a  'com- 
pend.'  It  is  modern  and  complete,  and  will  give  more  satisfaction  than  many  other  works 
which  are  perhaps  too  prolix  as  well  as  behind  the  times." — Medical  Review,  St.  Louis. 

CORWIN'S  PHYSICAL  DIAGNOSIS.     Third  Edition,  Revised. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur 
M.  Corwin,  A.M.,  M.D.,  Demonstrator  of  Physical  Diagnosis  in  Rush 
Medical  College,  Chicago  ;  Attending  Physician  to  Central  Free  Dis- 
pensary, Department  of  Rhinology,  Laryngology,  and  Diseases  of  the 
Chest,  Chicago.    219  pages,  illustrated.   Cloth,  flexible  covers,  $1.25  net. 

"  It  is  excellent.  The  student  who  shall  use  it  as  his  guide  to  the  careful  study  of 
physical  exploration  upon  normal  and  abnormal  subjects  can  scarcely  fail  to  acquire  a  good 
working  knowledge  of  the  subject." — Philadelphia  Polyclinic. 

"A  most  excellent  little  work.  It  brightens  the  memory  of  the  differential  diagnostic 
signs,  and  it  arranges  orderly  and  in  sequence  the  various  objective  phenomena  to  logical 
solution  of  a  careful  diagnosis. ' ' — Journal  oj  Nervous  and  Mental  Diseases. 

CRAGIN'S  GYNAECOLOGY.     Fourth  Edition,  Revised. 

Essentials  of  Gynaecology.     By  Edwin  B.  Cragin,  M.  D.,  Lecturer 

in  Obstetrics,  College  of  Physicians  and  Surgeons,  New  York.     Crown 

octavo,  200  pages;  62  illustrations.     Cloth,  $1.00  ;  interleaved  for  notes, 

$1-25- 

[See  Saunders'  Question- Compends,  page  23. J 

"  A  handy  volume,  and  a  distinct  improvement  on  students'  compends  in  general.  No 
author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the  student's  needs 
so  thoroughly  as  Dr.  Cragin  has  done." — Medical  Record,  New  York. 


12  Medical  Publications  of  W.  B.  Saunders. 

CROOKSHANK'S  BACTERIOLOGY.     Fourth  Edition,  Revised. 

A  Text=Book  of  Bacteriology.  By  Edgar  M.  Crookshank,  M.B., 
Professor  of  Comparative  Pathology  and  Bacteriology,  King's  College, 
London.  Octavo  volume  of  700  pages,  with  273  engravings  and  22 
original  colored  plates.     Cloth,  $6.50  net;   Half  Morocco,  $7.50  net. 

"  To  the  student  who  wishes  to  obtain  a  good  resume  of  what  has  been  done  in  bacteri- 
ology, or  who  wishes  an  accurate  account  of  the  various  methods  of  research,  the  book  may 
be  recommended  with  confidence  that  he  will  find  there  what  he  requires." — London  Lancet. 

Da  COSTA'S  SURGERY.  Second  Ed.,  Revised  and  Greatly  Enlarged. 
Modern  Surgery,  General  and  Operative.  By  John  Chalmers 
DaCosta,  M.D.,  Clinical  Professor  of  Surgery,  Jefferson  Medical 
College,  Philadelphia ;  Surgeon  to  the  Philadelphia  Hospital,  etc. 
Handsome  octavo  volume  of  900  pages,  profusely  illustrated.  Cloth, 
$4.00  net;  Half  Morocco,  $5.00  net. 

"We  know  of  no  small  work  on  surgery  in  the  English  language  which  so  well  fulfils 
the  requirements  of  the  modern  student." — Medico-Chirurgical  Journal,  Bristol,  England. 

DE  SCHWEINITZ  ON  DISEASES  OF  THE  EYE.      Third  Edition, 
Revised. 
Diseases  of   the  Eye.     A  Handbook   of   Ophthalmic   Practice. 

By  G.  E.  de  Schweinitz,  M.D.,  Professor  of  Ophthalmology  in  the 
Jefferson  Medical  College,  Philadelphia,  etc.  Handsome  royal  octavo 
volume  of  696  pages,  with  256  fine  illustrations  and  2  chromo-litho- 
graphic  plates.     Cloth,  $4.00  net ;  Sheep  or  Half  Morocco,  $5.00  net. 

"  A  clearly  written,  comprehensive  manual.  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering 
upon  the  study  of  this  special  branch  of  medical  science." — British  Aledical  Journal. 

"  A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.  I  am  satisfied  that  unusual  success  awaits  it." — William 
Pepper,  M.D.,  Professor  of  the  Theory  and  Practice  of  Medicine  and  Clinical  Medicine, 
University  of  Pennsylvania. 

DORLAND'S  DICTIONARY.     Second  Edition,  Revised. 

The  American  Pocket  Medical  Dictionary.  Containing  the  Pro- 
nunciation and  Definition  of  all  the  principal  words  and  phrases,  and  a 
large  number  of  useful  tables.  Edited  by  W.  A.  Newman  Dorland, 
M.  D.,  Assistant  Demonstrator  of  Obstetrics,  University  of  Pennsylvania; 
Fellow  of  the  American  Academy  of  Medicine.  518  pages  ;  handsomely 
bound  in  full  leather,  limp,  with  gilt  edges  and  patent  index.  Price, 
$1.00  net;  with  thumb  index,  $1.25  net. 

DORLAND'S  OBSTETRICS. 

A  Manual  of  Obstetrics.  By  W.  A.  Newman  Dorland,  M.D., 
Assistant  Demonstrator  of  Obstetrics,  University  of  Pennsylvania; 
Instructor  in  Gynecology  in  the  Philadelphia  Polyclinic.  760  pages; 
163  illustrations  in  the  text,  and  6  full-page  plates.      Cloth,  $2.50  net. 

"  By  far  the  best  book  on  this  subject  that  has  ever  come  to  our  notice." — American 
Medical  Review. 

"  It  has  rarely  been  our  duty  to  review  a  book  which  has  given  us  more  pleasure  in  its 
perusal  and  more  satisfaction  in  its  criticism.  It  is  a  veritable  encyclopedia  of  knowledge, 
a  gold  mine  of  practical,  concise  thoughts." — American  Medico-Surgical  Bulletin. 


Medical  Publications  of  W.  B.  Saunders.  13 

FROTHINGHAM'S  GUIDE  FOR  THE  BACTERIOLOGIST. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Froth- 
ingham,  M.D.V. ,  Assistant  in  Bacteriology  and  Veterinary  Science, 
Sheffield  Scientific  School,  Yale  University.    Illustrated.    Cloth,  75  cts. 

"  It  is  a  convenient  and  useful  little  work,  and  will  more  than  repay  the  outlay  neces- 
sary for  its  purchas-e  in  the  saving  of  time  which  would  otherwise  be  consumed  in  looking 
up  the  various  points  of  technique  so  clearly  and  concisely  laid  down  in  its  pages." — Ameri- 
can Medico- Surgical  Bulletin. 

GARRIGUES'  DISEASES  OF  WOMEN.  Third  Edition,  Revised. 
Diseases  of  Women.  By  Henry  J.  Garrigues,  A.M.,  M.D.,  Pro- 
fessor of  Gynecology  in  the  New  York  School  of  Clinical  Medicine ; 
Gynecologist  to  St.  Mark's  Hospital  and  to  the  German  Dispensary, 
New  York  City,  etc.  Handsome  octavo  volume  of  756  pages,  illus- 
trated by  367  engravings  and  colored  plates.  Cloth,  $4.00  net; 
Sheep  or  Half  Morocco,  $5.0*0  net. 

"  One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language  ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners  to  whom  experienced  consultants 
may  not  be  available  will  find  in  this  book  invaluable  counsel  and  help." — Thad.  A. 
Reamy,  M.D.,  LL.  D.,  Professor  of  Clinical  Gynecology,  Medical  College  of  Ohio. 

GLEASON'S  DISEASES  OF  THE  EAR.  Second  Edition,  Revised. 
Essentials  of  Diseases  of  the  Ear.  By  E.  B.  Gleason,  S.B., 
M.  D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College, 
Philadelphia  ;  Surgeon-in-Charge  of  the  Nose,  Throat,  and  Ear  Depart- 
ment of  the  Northern  Dispensary,  Philadelphia.  208  pages,  with 
114  illustrations.  Cloth,  $1.00;  interleaved  for  notes,  $1.25. 
[See  Saunders'  Question- Compends,  page   23.] 

"  It  is  just  the  book  to  put  into  the  hands  of  a  student,  and  cannot  fail  to  give  him  a 
useful  introduction  to  ear-affections  ;  while  the  style  of  question  and  answer  which  is  adopted 
throughout  the  book  is,  we  believe,  the  best  method  of  impressing  facts  permanently  on  the 
mind. ' ' — Liverpool  Medico-  Chirurgical  Journal. 

GOULD  AND  PYLE'S  CURIOSITIES  OF  MEDICINE. 

Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould, 
M.D.,  and  Walter  L.  Pyle,  M.D.  An  encyclopedic  collection  of 
rare  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an 
exhaustive  research  of  medical  literature  from  its  origin  to  the  present 
day,  abstracted,  classified,  annotated,  and  indexed.  Handsome  im- 
perial octavo  volume  of  968  pages,  with  295  engravings  in  the  text, 
and  12  full-page  plates. 

POPULAR   EDITION  :  Cloth,  $3.00  net  .•  Half  Morocco,  $4.00  net. 

"  One  of  the  most  valuable  contributions  ever  made  to  medical  literature.  It  is,  so  far 
as  we  know,  absolutely  unique,  and  every  page  is  as  fascinating  as  a  novel.  Not  alone  for 
the  medical  profession  has  this  volume  value :  it  will  serve  as  a  book  of  reference  for  all  who 
are  interested  in  general  scientific,  sociologic,  or  medico-legal  topics." — Brooklyn  Medical 
Journal. 

"This  is  certainly  a  most  remarkable  and  interesting  volume.  It  stands  alone  among 
medical  literature,  an  anomaly  on  anomalies,  in  that  there  is  nothing  like  it  elsewhere  in 
medical  literature.  It  is  a  book  full  of  revelations  from  its  first  to  its  last  page,  and  cannot 
but  interest  and  sometimes  almost  horrify  its  readers." — American  Medico- Surgical  Bulletin. 


14  Medical  Publications  of  W.  B.  Saunders. 

GRAFSTROM'S   MECHANOTHERAPY. 

A  Text=Book  of  Mechanotherapy  (Massage  and  Medical  Gym= 
nasties).  By  Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  late  Lieutenant  in 
the  Royal  Swedish  Army  ;  late  House  Physician  City  Hospital,  Black- 
well's  Island,  New  York.    i2mo,  139  pages,  illustrated.    Cloth,  $1.00  net. 

GRIFFITH  ON  THE  BABY.     Second  Edition,  Revised. 

The  Care  of  the  Baby.  By  J-  P-  Crozer  Griffith,  M.D.,  Clini- 
cal Professor  of  Diseases  of  Children,  University  of  Pennsylvania ; 
Physician  to  the  Children's  Hospital,  Philadelphia,  etc.  121110,  404 
pages,  with  67  illustrations  in  the  text,  and  5  plates.      Cloth,  #1.50. 

"  The  best  book  for  the  use  of  the  young  mother  with  which  we  are  acquainted.  .  .  . 
There  are  very  few  general  practitioners  who  could  not  read  the  book  through  with  advan- 
tage."— Archives  of  Pediatrics. 

"The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a 
master  hand.  It  can  be  read  with  benefit  not  only  by  mothers  but  by  medical  students  and 
by  any  practitioners  who  have  not  had  large  opportunities  for  observing  children." — Ameri- 
can Journal  of  Obstetrics. 

GRIFFITH'S  WEIGHT  CHART. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D. , 
Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Penn- 
sylvania, etc.      25  charts  in  each  pad.      Per  pad,  50  cents  net. 

GROSS,  SAMUEL  D.,  AUTOBIOGRAPHY  OF. 

Autobiography  of  Samuel  D.  Gross,  M.  D.,  Emeritus  Professor  of 
Surgery  in  the  Jefferson  Medical  College,  Philadelphia,  with  Remi- 
niscences of  His  Times  and  Contemporaries.  Edited  by  his  Sons, 
Samuel  W.  Gross,  M.D.,  LL. D.,  and  A.  Haller  Gross,  A.M.  Pre- 
ceded by  a  Memoir  of  Dr.  Gross,  by  the  late  Austin  Flint,  M.D. 
Two  handsome  volumes,  over  400  pages  each,  demy  octavo,  gilt  tops, 
with  Frontispiece  on  steel.      Price  per  volume,  $2.50  net. 

HAMPTON'S  NURSING.  Second  Edition,  Revised  and  Enlarged. 
Nursing:  Its  Principles  and  Practice.  By  Isabel  Adams  Hamp- 
ton, Graduate  of  the  New  York  Training  School  for  Nurses  attached 
to  Bellevue  Hospital ;  late  Superintendent  of  Nurses  and  Principal  of 
the  Training  School  for  Nurses,  Johns  Hopkins  Hospital,  Baltimore, 
Md.     12  mo,  512  pages,  illustrated.     Cloth,  $2.00  net. 

"  Seldom  have  we  perused  a  book  upon  the  subject  that  has  given  us  so  much  pleasure 
as  the  one  before  us.  We  would  strongly  urge  upon  the  members  of  our  own  profession  the 
need  of  a  book  like  this,  for  it  will  enable  each  of  us  to  become  a  training  school  in  him- 
self."—  Ontario  Medical  Journal. 

HARE'S  PHYSIOLOGY.  Fourth  Edition,  Revised. 

Essentials  of  Physiology.  By  H.  A.  Hare,  M.D.,  Professor  of 
Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical  College  of 
Philadelphia.  Crown  octavo,  239  pages.  Cloth,  #1.00  net;  inter- 
leaved for  notes,  #1.25  net. 

[See  Saunders''  Question- Compends,  page  23.] 

"The  best  condensation  of  physiological  knowledge  we  have  yet  seen." — Medical 
Record,  New  York. 


Medical  Publications  of  W.  B.  Saunders.  15 


HART'S  DIET  IN  SICKNESS  AND  IN  HEALTH. 

Diet  in  Sickness  and  in  Health.  By  Mrs.  Ernest  Hart,  formerly 
Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London  School 
of  Medicine  for  Women ;  with  an  Introduction  by  Sir  Henry 
Thompson,  F.R.C.S.,  M.D.,  London.     220  pages.      Cloth,  $1.50. 

"  We  recommend  it  cordially  to  the  attention  of  all  practitioners ;  both  to  them  and  to 
their  patients  it  may  be  of  the  greatest  service." — New  York  Medical  Journal. 

HAYNES'  ANATOMY. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Depart- 
ment of  the  New  York  University,  etc.  680  pages,  illustrated  with  42 
diagrams  in  the  text,  and  134  full-page  half-tone  illustrations  from 
original  photographs  of  the  author's  dissections.      Cloth,  $2.50  net. 

"  This  book  is  the  work  of  a  practical  instructor — one  who  knows  by  experience  the 
requirements  of  the  average  student,  and  is  able  to  meet  these  requirements  in  a  very  satis- 
factory way.      The  book  is  one  that  can  be  commended." — Medical  Record,  New  York. 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.D.,  Pro- 
fessor of  Anatomy  in  the  Medico- Chirurgical  College,  Philadelphia.  Oc- 
tavo volume  of  405  pages,  handsomely  illustrated.    Cloth,  $2.50  net. 

HIRST'S  OBSTETRICS.  Second  Edition. 

A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome 
octavo  volume  of  848  pages,  with  618  illustrations,  and  7  colored 
plates.     Cloth,  $5.00  net;   Sheep  or  Half  Morocco,  $6.00  net. 

"The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the 
first  time.  The  arrangement  of  the  subject-matter,  the  foot-notes,  and  index  are  beyond 
criticism.  As  a  true  model  of  what  a  modern  text-book  on  obstetrics  should  be,  we  feel 
justified  in  affirming  that  Dr.  Hirst's  book  is  without  a  rival." — New  York  Medical  Record. 

HYDE  AND  MONTGOMERY  ON  SYPHILIS  AND  THE  VENEREAL 
DISEASES. 
Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde, 
M.D.,  Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  Mont- 
gomery, M.D.,  Lecturer  on  Dermatology  and  Genito-Urinary  Diseases 
in  Rush  Medical  College,  Chicago,  111.  618  pages,  profusely  illustrated. 
Cloth,  $2.50  net. 

"  We  can  commend  this  manual  to  the  student  as  a  help  to  him  in  his  study  of  venereal 
diseases. ' ' — Liverpool  Medico-  Chirurgical  Journal. 

"The  best  student's  manual  which  has  appeared  on  the  subject." — St.  Leuis  Medical 
and  Surgical  Journal. 

INTERNATIONAL  TEXT=BOOK  OF  SURGERY.  In  two  volumes. 
By  American  and  British  authors.  Edited  by  J.  Collins  Warren, 
M.D.,  LL.D.,  Professor  of  Surgery,  Harvard  Medical  School,  Boston; 
and  A.  Pearce  Gould,  M.S.,  F.R.C.S.,  Lecturer  on  Practical  Sur- 
gery and  Teacher  of  Operative  Surgery,  Middlesex  Hospital  Medical 
School,  London,  Eng.  Vol.  I.  General  Surgery. — Handsome  octavo, 
947  pages,  with  458  beautiful  illustrations  and  9  lithographic  plates. 
Vol.  II.  Special  or  Regional  Surgery. — Handsome  octavo,  1072  pages, 
with  471  beautiful  illustrations  and  8  lithographic  plates.  Prices  per 
volume:    Cloth,  $5.00  net;   Half  Morocco,  $6.00  net. 


16  Medical  Publications  of  W.  B.  Saunders. 

JACKSON'S  DISEASES  OF  THE  EYE. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.M., 
M.D.,  sometime  Professor  of  Diseases  of  the  Eye  in  the  Philadelphia 
Polyclinic  and  College  for  Graduates  in  Medicine.  1 2mo  volume  of 
535  Pages>  witn  X7S  beautiful  illustrations,  mostly  from  drawings  by  the 
author.      Cloth,  $2.50  net. 

JACKSON  AND  GLEASON'S  DISEASES  OF  THE  EYE,  NOSE,  AND 
THROAT.  Second  Edition,  Revised. 
Essentials  of  Refraction  and  Diseases  of  the  Eye.  By  Edward 
Jackson,  A.M.,  M.D.,  Professor  of  Diseases  of  the  Eye  in  the  Phila- 
delphia Polyclinic  and  College  for  Graduates  in  Medicine ;  and — 
Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  Bald- 
win Gleason,  M.D.,  Surgeon-in-Charge  of  the  Nose,  Throat,  and 
Ear  Department  of  the  Northern  Dispensary  of  Philadelphia.  Two 
volumes  in  one.  Crown  octavo,  290  pages;  124  illustrations.  Cloth, 
$1.00;  interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  22.] 

"  Of  great  value  to  the  beginner  in  these  branches.  The  authors  are  both  capable  men, 
and  know  what  a  student  most  needs." — Medical  Record,  New  York. 

KEATING'S  DICTIONARY.     Second  Edition,  Revised. 

A  New  Pronouncing  Dictionary  of  Medicine,  with  Phonetic 
Pronunciation,  Accentuation,  Etymology,  etc.  By  John  M. 
Keating,  M.D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia, and  Henry  Hamilton  ;  with  the  collaboration  of  J.  Chal- 
mers DaCosta,  M.D.,  and  Frederick  A.  Packard,  M.D.  With  an 
Appendix  containi  g  Tables  of  Bacilli,  Micrococci,  Leucoma'ines, 
Ptomaines,  etc.  One  volume  of  over  800  pages.  Prices,  with  Ready- 
Reference  Index:  Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  $6.00 
net.  Without  Patent  Index:  Cloth,  $4.00  net;  Sheep  or  Half  Morocco, 
$5.00  net. 

"I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommend- 
ing it  to  my  classes." — Henry  M.  Lyman,  M.  D.,  Professor  of  the  Principles  and  Practice 
<9f  Medicine,  Rush  Medical  College,  Chicago,  III. 

KEATING'S   LIFE   INSURANCE. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating, 
M.  D.,  Fellow  of  the  College  of  Physicians  of  Philadelphia;  Vice- 
President  of  the  American  Pediatric  Society;  Ex- President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages ;  with  two  large  half-tone  illustrations,  and  a  plate  prepared  by 
Dr.  McClellan  from  special  dissections ;  also,  numerous  other  illustra- 
tions.    Cloth,  $2.00  net. 

KEEN'S  OPERATION  BLANK.     Second  Edition,  Revised  Form. 
An  Operation  Blank,  with   Lists  of  Instruments,  etc.,  Required 
in  Various  Operations.     Prepared  by  W.  W.  Keen,  M.D.,  LL.D., 
Professor  of  the  Principles  of  Surgery  in  Jefferson  Medical  College, 
Philadelphia.     Price  per  pad,  blanks  for  fifty  operations,  50  cents  net. 


Medical  Publications  of  W.  B.  Saunders.  17 


KEEN  ON  THE  SURGERY  OF  TYPHOID  FEVER. 

The    Surgical   Complications  and   Sequels  of   Typhoid    Fever. 

By  Wm.  W.  Keen,  M.D.,  LL.D.,  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia; 
Corresponding  Member  of  the  Societe  de  Chirurgie,  Paris ;  Honorary 
Member  of  the  Societe  Beige  de  Chirurgie,  etc.  Octavo  volume  of" 
386  pages,  illustrated.      Cloth,  $3.00  net. 

"  This  is  probably  the  first  and  only  work  in  the  English  language  that  gives  the  reader 
a  clear  view  of  what  typhoid  fever  really  is,  and  what  it  does  and  can  do  to  the  human 
organism.  This  book  should  be  in  the  possession  of  every  medical  man  in  America." — 
American  Medico-Surgical  Bulletin. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.D., 
Clinical  Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical 
College,  Philadelphia ;  Consulting  Laryngologist,  Rhinologist,  and 
Otologist,  St.  Agnes'  Hospital.  Handsome  octavo  volume  of  about 
630  pages,  with  over  150  illustrations  and  6  lithographic  plates.  Price, 
Cloth,  $4.00  net;   Half  Morocco,  $5.00  net. 

LAINE'S  TEMPERATURE  CHART. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.D.  Size  8x13^ 
inches.  A  conveniently  arranged  Chart  for  recording  Temperature, 
with  columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions, 
Food,  Remarks,  etc.  On  the  back  of  each  chart  is  given  in  full  the 
method  of  Brand  in  the  treatment  of  Typhoid  Fever.  Price,  per  pad 
of  25  charts,  50  cents  net. 

"  To  the  busy  practitioner  this  chart  will  be  found  of  great  value  in  fever  cases,  and 
especially  for  cases  of  typhoid." — Indian  Lancet,  Calcutta. 

LEVY   AND   KLEMPERER'S   CLINICAL  BACTERIOLOGY. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Ernst  Levy,  Profes- 
sor in  the  University  of  Strassburg,  and  Felix  Klemperer,  Privat  docent 
in  the  University  of  Strassburg.  Translated  and  edited  by  Augustus 
A.  Eshner,  M.D.,  Professor  of  Clinical  Medicine  in  the  Philadelphia 
Polyclinic.     Octavo,  440  pages,  fully  illustrated.     Cloth,  $.        net. 

LOCKWOOD'S  PRACTICE  OF  MEDICINE. 

A  Manual  of  the  Practice  of  Medicine.  By  George  Roe  Lock- 
wood,  M.D.,  Professor  of  Practice  in  the  Woman's  Medical  College 
of  the  New  York  Infirmary,  etc.  935  pages,  with  75  illustrations  in 
the  text,  and  22  full-page  plates.      Cloth,  $2.50  net. 

"  Gives  in  a  most  concise  manner  the  points  essential  to  treatment  usually  enumerated 
in  the  most  elaborate  works." — Massachusetts  Medical  Journal. 

LONG'S  SYLLABUS  OF  GYNECOLOGY. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An 
American  Text=Book  of  Gynecology."  By  J.  W.  Long,  M.D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of 
Virginia,  etc.      Cloth,  interleaved,  $1.00  net. 

"  The  book  is  certainly  an  admirable  resume  of  what  every  gynecological  student  and 
practitioner  should  know,  and  will  prove  of  value  not  only  to  those  who  have  the  '  American 
Text-Book  of  Gynecology,'  but  to  others  as  well." — Brooklyn  Medical  Journal. 
2 


18  Medical  Publications  of  W.  B.  Saunders. 

MACDONALD'S  SURGICAL  DIAGNOSIS  AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.D. 
Edin.,  F.R.  C.S.,  Edin.,  Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery  in  Hamline  University;  Visiting  Surgeon  to  St. 
Barnabas'  Hospital,  Minneapolis,  etc.  Handsome  octavo  volume  of 
800  pages,  profusely  illustrated.  Cloth,  $5.00  net;  Half  Morocco, 
So.  00  net. 

"  A  thorough  and  complete  work  on  surgical  diagnosis  and  treatment,  free  from  pad- 
ding, full  of  valuable  material,  and  in  accord  with  the  surgical  teaching  of  the  day." — The 

Medical  Netos,  ATew  York. 

"  The  work  is  brimful  of  just  the  kind  of  Practical  information  that  is  useful  alike  to 
students  and  practitioners.  It  is  a  pleasure  to  commend  the  bock  because  of  its  intrinsic 
value  to  the  medical  practitioner."  —  Cincinnati  Lancet-Clinic 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work 
in  Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on 
Post-Mortem  Technique  and  the  Performance  of  Autopsies.  By  Frank 
B.  Mallory,  A.M.,  M.D.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston;  and  James  H.  Wright,  A.M., 
M.D.,  Instructor  in  Pathology,  Harvard  University  Medical  School, 
Boston.  Octavo  volume  of  396  pages,  handsomely  illustrated.  Cloth, 
$2.50  net. 

"  I  have  been  looking  forward  to  the  publication  of  this  book,  and  I  am  glsd  to  say  that 
I  find  it  to  be  a  most  useful  laboratory  and  post-mortem  guide,  full  of  practical  information, 
and  well  up  to  date." — William  H.  Welch,  Professor  of  Pathology,  Johns  Hopkins  Uni- 
versity, Baltimore,  Md. 

MARTIN'S  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 
DISEASES.  Second  Edition,  Revised. 
Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal 
Diseases.  By  Edward  Martin,  A.M.,  M.D.,  Clinical  Professor  of 
Genito-Urinary  Diseases,  University  of  Pennsylvania,  etc.  Crown 
octavo,  166  pages,  with  78  illustrations.  Cloth,  $1.00;  interleaved  for 
notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  23.] 

"A  very  practical  and  systematic  study  of  the  subjects,  and  shows  the  author's  famil- 
iarity with  the  needs  of  students." — Therapeutic  Gazette. 

MARTIN'S  SURGERY.     Seventh  Edition,  Revised. 

Essentials  of  Surgery.  Containing  also  Venereal  Diseases,  Surgi- 
cal Landmarks,  Minor  and  Operative  Surgery,  and  a  complete  de- 
scription, with  illustrations,  of  the  Handkerchief  and  Roller  Bandages. 
By  Edward  Martin,  A.M.,  M.D.,  Clinical  Professor  of  Genito- 
Urinary  Diseases,  University  of  Pennsylvania,  etc.  Crown  octavo,  342 
pages,  illustrated.  With  an  Appendix  on  the  preparation  of  the  materials 
used  in  Antiseptic  Surgery,  etc.,  and  a  chapter  on  Appendicitis.  Cloth, 
$1.00  net;  interleaved  for  notes,  $1.25  net 

[See  Saunders''  Question- Compends,  page  23.] 

"Contains  all  necessary  essentials  of  modern  surgery  in  a  comparatively  small  space. 
Its  style  is  interesting,  and  its  illustrations  are  admirable." — Medical  and  Surgical  Reporter. 


Medical  Publications  of  W.  B.  Saunders.  19 

McFARLAND'S  PATHOGENIC  BACTERIA.  Second  Edition,  Re- 
vised and  Greatly  Enlarged. 
Text=Book  upon  the  Pathogenic  Bacteria.  By  Joseph  McFar- 
land,  M.  D.,  Professor  of  Pathology  and  Bacteriology  in  the  Medico- 
Chirurgical  College  of  Philadelphia,  etc.  Octavo  volume  of  497  pages, 
finely  illustrated.     Cloth,  $2.50  net. 

"  Dr.  McFarland  has  treated  the  subject  in  a  systematic  manner,  and  has  succeeded  in 
presenting  in  a  concise  and  readable  form  the  essentials  of  bacteriology  up  to  date.  Alto- 
gether, the  book  is  a  satisfactory  one,  and  I  shall  take  pleasure  in  recommending  it  to  the 
students  of  Trinity  College." — H.  B.  Anderson,  M.D. ,  Professor  of  Pathology  and  Bac- 
teriology, Trinity  Medical  College,  Toronto. 

MEIGS  ON  FEEDING  IN  INFANCY. 

Feeding  in  Early  Infancy.  By  Arthur  V.  Meigs,  M.D.  Bound 
in  limp  cloth,  flush  edges,  25  cents  net. 

"This  pamphlet  is  worth  many  times  over  its  price  to  the  physician.  The  author's 
experiments  and  conclusions  are  original,  and  have  been  the  means  of  doing  much  good."— 
Medical  Bulletin. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.D., 
Professor  of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery, 
University  of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo 
volume  of  356  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

"A  most  attractive  work.  The  illustrations  and  the  care  with  which  the  book  is  adapted 
to  the  wants  of  the  general  practitioner  and  the  student  are  worthy  of  great  praise." — Chicago 
Medical  Recorder. 

"A  very  demonstrative  work,  every  illustration  of  which  conveys  a  lesson.  The  work  is 
a  most  excellent  and  commendable  one,  which  we  can  certainly  endorse  with  pleasure." — 
St.  Louis  Medical  and  Surgical  Journal. 

MORRIS'S  MATERIA  MEDICA  AND  THERAPEUTICS.  Fifth 
Edition,  Revised. 
Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription 
Writing.  By  Henrv  Morris,  M.D.,  late  Demonstrator  of  Thera- 
peutics, Jefferson  Medical  College,  Philadelphia ;  Fellow  of  the  College 
of  Physicians,  Philadelphia,  etc.  Crown  octavo,  288  pages.  Cloth, 
$1.00  ;  interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Compends,  page   22.] 

"  This  work,  already  excellent  in  the  old  edition,  has  been  largely  improved  by  revi- 
sion." — American  Practitioner  and  News. 

MORRIS,  WOLFF,  AND  POWELL'S  PRACTICE  OF  MEDICINE, 
Third  Edition,  Revised. 
Essentials  of  the  Practice  of  Medicine.  By  Henry  Morris,  M.D., 
late  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia ;  with  an  Appendix  on  the  Clinical  and  Microscopic  Examina- 
tion of  Urine,  by  Lawrence  Wolff,  M.D.,  Demonstrator  of  Chemistry, 
Jefferson  Medical  College,  Philadelphia.  Enlarged  by  some  300  essen- 
tial formulas  collected  and  arranged  by  William  M.  Powell,  M.D. 
Post-octavo,  488  pages.      Cloth,  $2.00. 

[See  Saunders'  Question- Compends,  page   22.] 

"  The  teaching  is  sound,  the  presentation  graphic  ;  matter  full  as  can  be  desired,  and 
Style  attractive." — American  Practitioner  and  News. 


20  Medical  Publications  of  W.  B.  Saunders. 

MORTEN'S  NURSE'S  DICTIONARY. 

Nurse's  Dictionary  of  Medical  Terms  and  Nursing  Treat- 
ment. Containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms  and  Abbreviations ;  of  the  Instruments,  Drugs,  Diseases,  Acci- 
dents, Treatments,  Operations,  Foods,  Appliances,  etc.  encountered 
in  the  ward  or  in  the  sick-room.  By  Honnor  Morten,  author  of 
"How  to  Become  a  Nurse,"  etc.     i6mo,  140  pages.      Cloth,  $1.00. 

"  A  handy,  compact  little  volume,  containing  a  large  amount  of  general  information,  all 
of  which  is  arranged  in  dictionary  or  encyclopedic  form,  thus  facilitating  quick  reference. 
It  is  certainly  of  value  to  those  for  whose  use  it  is  published." — Chicago  Clinical  Review. 

NANCREDE'S  ANATOMY.  Sixth  Edition,  Thoroughly  Revised. 
Essentials  of  Anatomy,  including  the  Anatomy  of  the  Viscera. 
By  Charles  B.  Nancrede,  M.D.,  LL.D.,  Professor  of  Surgery  and 
of  Clinical  Surgery  in  the  University  of  Michigan,  Ann  Arbor.  Crown 
octavo,  420  pages;  151  illustrations.  Based  upon  Gray's  Anatomy. 
Cloth,  Si. 00  net  ;   interleaved  for  notes,  $1.25  net. 

[See  Sounders'  Question- Compends,  page  23.] 

"  For  self-quizzing  and  keeping  fresh  in  mind  the  knowledge  of  anatomy  gained  at 
school,  it  would  not  be  easy  to  speak  of  it  in  terms  too  favorable." — American  Practitioner. 

NANCREDE'S  ANATOMY  AND  DISSECTION.     Fourth  Edition. 
Essentials  of  Anatomy  and    Manual  of   Practical    Dissection. 

By  Charles  B.  Nancrede,  M.D.,  LL.D.,  Professor  of  Surgery  and  of 
Clinical  Surgery,  University  of  Michigan,  Ann  Arbor.  Post-octavo  ; 
500  pages,  with  full-page  lithographic  plates  in  colors,  and  nearly  200 
illustrations.     Extra  Cloth  (or  Oilcloth  for  dissection-room),  $2.00  net. 

"  It  may  in  many  respects  be  considered  an  epitome  of  Gray's  popular  work  on  general 
anatomy,  at  the  same  time  having  some  distinguishing  characteristics  of  its  own  to  commend 
it.  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students 
in  their  work  in  the  dissecting  room." — Journal  of  the  American  Medical  Association. 

NANCREDE'S  PRINCIPLES  OF  SURGERY. 

Lectures  on  the  Principles  of  Surgery.  By  Chas.  B.  Nancrede, 
M.D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  Univer- 
sity of  Michigan,  Ann  Arbor.  Octavo  volume  of  398  pages,  illustrated. 
Cloth,  $2- 5°  net. 

NORRIS'S  SYLLABUS  OF  OBSTETRICS.  Third  Edition,  Revised. 
Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department 
of  the  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.M.,  M.D.,  Demonstrator  of  Obstetrics,  University  of  Pennsylvania. 
Crown  octavo,  222  pages.      Cloth,  interleaved  for  notes,  $2.00  net. 

PENROSE'S  DISEASES  OF  WOMEN.     Third  Edition,  Revised. 
A  Text=Book  of  Diseases  of  Women.     By  Charles  B.  Penrose, 
M.  D.,  Ph.D.,  Formerly  Professor  of  Gynecology  in  the  University 
of  Pennsylvania ;    Surgeon   to   the   Gynecean   Hospital,    Philadelphia. 
Octavo  volume  of  531  pages,  handsomely  illustrated.    Cloth,  $3.75  net. 

"I  shall  value  very  highly  the  copy  of  Penrose's  'Diseases  of  Women'  received. 
I  have  already  recommended  it  to  my  class  as  THE  BEST  book."— Howard  A.  Kelly, 
Professor  of  Gynecology  and  Obstetrics,  Johns  Hopkins  University,  Baltimore,  Md. 


Medical  Publications  of  W.  B.  Saunders.  21 

POWELL'S  DISEASES  OF  CHILDREN.     Second  Edition. 

Essentials  of  Diseases  of  Children.  By  William  M.  Powell, 
M.D.,  Attending  Physician  to  the  Mercer  House  for  Invalid  Women 
at  Atlantic  City,  N.  J.  ;  late  Physician  to  the  Clinic  for  the  Diseases  of 
Children  in  the  Hospital  of  the  University  of  Pennsylvania.  Crown 
octavo,  222  pages.     Cloth,  $1.00;  interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Comjends,  page  21.] 

"Contains  the  gist  of  all  the  best  works  in  the  department  to  which  it  relates."— 
American  Practitioner  and  News. 

PRINGLE'S  SKIN  DISEASES  AND  SYPHILITIC  AFFECTIONS. 
Pictorial  Atlas  of  Skin  Diseases  and  Syphilitic  Affections 
(American  Edition).  Translation  from  the  French.  Edited  by 
J.  J.  Pringle,  M.B.,  F.R.C.P.,  Assistant  Physician  to  the  Middlesex 
Hospital,  London.  Photo-lithochromes  from  the  famous  models  in 
the  Museum  of  the  Saint-Louis  Hospital,  Paris,  with  explanatory  wood- 
cuts and  text.  In  12  Parts.  Price  per  Part,  $3.00.  Complete  in 
one  volume,  Half  Morocco  binding,  $40.00  net. 

"  I  strongly  recommend  this  Atlas.  The  plates  are  exceedingly  well  executed,  and 
will  be  of  great  value  to  all  studying  dermatology." — Stephen  Mackenzie,  M.D. 

"The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say,  has  been  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — New  York  Medical  Journal. 

PRYOR— PELVIC  INFLAMMATIONS. 

The  Treatment  of   Pelvic  Inflammations  through  the  Vagina. 

By  W.  R.  Pryor,  M.D.,  Professor  of  Gynecology  in  New  York  Poly- 
clinic.     121110,  248  pages,  handsomely  illustrated.     Cloth,  $2.00  net. 

"  This  subject,  which  has  recently  been  so  thoroughly  canvassed  in  high  gynecological 
circles,  is  made  available  in  this  volume  to  the  general  practitioner  and  student.  Nothing  is 
too  minute  for  mention  and  nothing  is  taken  for  granted  ;  consequently  the  book  is  of  the  utmost 
value.    The  illustrations  and  the  technique  are  beyond  criticism." — Chicago  Medical  Recorder. 

PYE'S  BANDAGING. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Direc- 
tions concerning  the  Immediate  Treatment  of  Cases  of  Emergency. 
For  the  use  of  Dressers  and  Nurses.  By  Walter  Pye,  F.R.C.S.,  late 
Surgeon  to  St.  Mary's  Hospital,  London.  Small  121110,  with  over  80 
illustrations.     Cloth,  flexible  covers,  75  cents  net. 

"The  directions  are  clear  and  the  illustrations  are  good."— London  Lancet. 
"  The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  port- 
able, although  the  paper  and  type  are  good." — British  Medical  Journal. 

RAYMOND'S  PHYSIOLOGY. 

A  Manual  of  Physiology.  By  Joseph  H.  Raymond,  A.M.,  M.D., 
Professor  of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in 
the  Long  Island  College  Hospital ;  Director  of  Physiology  in  the 
Hoagland  Laboratory,  etc.  382  pages,  with  102  illustrations  in  the 
text,  and  4  full-page  colored  plates.      Cloth,  $1.25  net. 

"  Extremely  well  gotten  up,  and  the  illustrations  have  been  selected  with  care.  The 
text  is  fully  abreast  with  modern  physiology." — British  Medical  Journal. 


>AUNDERS' 

Question 


Compends 


Arranged  in  Question  and 
Answer  Form, 

HTHE  MOST  COMPLETE  AND  BEST 
ILLUSTRATED  SERIES  OF 


COMPENDS  EVER  ISSUED. 

Now  the  Standard  Authorities  in  Medical  Literature  .... 

with  Students  and  Practitioners  in  every  City  of  the  United  States  and  Canada* 


^> 


^    OVER  175,000  COPIES  SOLD.    ^ 
THE  REASON  WHY. 

They  are  the  advance  guard  of  "Student's  Helps" — that  DO  help.  They  are  the 
leaders  in  their  special  line,  well  and  authoritatively  written  by  able  men,  who,  as  teachers  in 
the  large  colleges,  know  exactly  what  is  wanted  by  a  student  preparing  for  his  examinations. 
The  judgment  exercised  in  the  selection  of  authors  is  fully  demonstrated  by  their  professional 
standing.  Chosen  from  the  ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of 
them  have  become  Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250  pages, 
profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on  fine  paper. 

The  entire  series,  numbering  twenty-three  volumes,  has  been  kept  thoroughly  revised 
and  enlarged  when  necessary,  many  of  the  books  being  in  their  fifth  and  sixth  editions. 

TO  SUM  UP. 

Although  there  ar£  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  market,  none  of 
them  approach  the  "  Blue  Series  of  Question  Compends;"  and  the  claim  is  made  for  the 
following  points  of  excellence  : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Quality  of  illustrations,  paper,  printing,  and  binding. 

Any  cf  these  Compends  will  be   mailed  on  receipt  of  price  (see  next  page  for  List). 


Oaunders'  v^uestion-Compend  Series* 

Price,  Cloth,  $1.00  per  copy,  except  when  otherwise  noted. 


"Where   the  work   of  preparing  students'  manuals   is   to   end  we   cannot   say,  but  the 
Saunders  Series,  in  our  opinion,  bears  off  the  palm  at  present."— New  York  Medical  Record. 


1.  ESSENTIALS  OF  PHYSIOLOGY.     By  H.  A.  Hare,  M.D.    Fourth  edition, 

revised  and  enlarged.      ($1.00  net.) 

2.  ESSENTIALS  OF  SURGERY.     By  Edward  Martin,  M.  D.     Seventh  edition, 

revised,  with  an  Appendix  and  a  chapter  on  Appendicitis.      ($i.oo  net.) 

3.  ESSENTIALS   OF   ANATOMY.      By  Chari.es  B.   Nancrede,  M.D.      Sixth 

edition,  thoroughly  revised  and  enlarged.      ($i.oo  net.) 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

By  Lawrence  Wolff,  M.D.     Fifth  edition,  revised.     (JSi.oo  net.) 

5.  ESSENTIALS  OF  OBSTETRICS.     By  W.  Easterly  Ashton,  M.D.     Fourth 

edition,  revised  and  enlarged. 

6.  ESSENTIALS  OF  PATHOLOGY  AND  MORBID  ANATOMY.     By  C.  E. 

Armand  Semple,  M.D. 

7.  ESSENTIALS  OF  MATERIA  MED1CA,  THERAPEUTICS,  AND   PRE- 

SCRIPTION=WRITING.    By  Henry  Morris,  M.D.       Fifth  edition,  revised. 

8.  9.    ESSENTIALS   OF   PRACTICE    OF   MEDICINE.      By   Henry   Morris, 

M.D.  An  Appendix  on  Urine  Examination.  By  Lawrence  Wolff,  M.D. 
Third  edition,  enlarged  by  some  300  Essential  Formulas,  selected  from  eminent 
authorities,  by  Wm.  M.  Powell,  M.D.     (Double  number,  $2.00.) 

10.  ESSENTIALS  OF  GYNAECOLOGY.      By  Edwin  B.  Cragin,  M.D.      Fourth 

edition,  revised. 

11.  ESSENTIALS  OF  DISEASES  OF  THE  SKIN.     By  Henry  W.  Stelwagon, 

M.D.     Fourth  edition,  revised  and  enlarged.      ($1.00  net.) 

12.  ESSENTIALS  OF  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 

DISEASES.     By  Edward  Martin,  M.D.     Second  ed.,  revised  and  enlarged. 

13.  ESSENTIALS  OF  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 

By  C.  E.  Armand  Semple,  M.D. 

14.  ESSENTIALS  OF   DISEASES  OF  THE   EYE,  NOSE,  AND  THROAT. 

By  Edward  Jackson,  M.D.,  and  E.  B.  Gleason,  M.D.     Second  ed.,  revised. 

15.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.     By  William  M.  Powell, 

M.D.     Second  edition. 

16.  ESSENTIALS  OF   EXAMINATION    OF   URINE.     By   Lawrence  Wolff, 

M.D.      Colored  "  Vogel  Scale."      (75  cents. ) 

17.  ESSENTIALS  OF  DIAGNOSIS.     By  S.  Solis  Cohen,  M.D.,  and  A.  A.  Eshner, 

M.D.      Second  edition,  thoroughly  revised.      ($1.00  net.) 

18.  ESSENTIALS  OF  PRACTICE   OF   PHARMACY.     By   Lucius   E.    Sayre. 

Second  edition,  revised  and  enlarged. 

20.  ESSENTIALS  OF  BACTERIOLOGY.     By  M.  V.  Ball,  M.D.     Third  edition, 

revised. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY.     By  John  C. 

Shaw,  M.D.     Third  edition,  revised. 

22.  ESSENTIALS  OF   MEDICAL  PHYSICS.      By   Fred  J.    Brockway,    M.D. 

Second  edition,  revised.      ($1.00  net.) 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.    By  David  D.  Stewart,  M.D. , 

and  Edward  S.  Lawrance,  M.D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE   EAR.      By  E.  B.  Gleason,  M.D. 

Second  edition,  revised  and  greatly  enlarged. 


Pamphlet  containing  specimen  pages,  etc.  sent  free  upon  application. 


Saunders' 

New  Series 
of  Manuals 


for  Students 
and 
Practitioners. 


*  I  'HAT  there  exists  a  need  for  thoroughly  reliable  hand-books  on  the  leading  branches 
of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the  favor  with  which 
the  SAUNDERS  NEW  SERIES  OF  MANUALS  have  been  received-  by  medical 
students  and  practitioners  and  by  the  Medical  Press,  These  manuals  are  not  merely 
condensations  from  present  literature,  but  are  ably  written  by  well-known  authors 
and  practitioners,  most  of  them  being  teachers  in  representative  American  colleges. 
Each  volume  is  concisely  and  authoritatively  written  and  exhaustive  in  detail,  without 
being  encumbered  with  the  introduction  of  "cases,"  which  so  largely  expand  the 
ordinary  text-book.  These  manuals  will  therefore  form  an  admirable  collection  of 
advanced  lectures,  useful  alike  to  the  medical  student  and  the  practitioner:  to  the 
latter,  too  busy  to  search  through  page  after  page  of  elaborate  treatises  for  what  he 
wants  to  know,  they  will  prove  of  inestimable  value ;  to  the  former  they  will  afford 
safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  OF  MANUALS  are  conceded  to  be  superior 
to  any  similar  books  now  on  the  market.  No  other  manuals  afford  so  much  infor- 
mation in  such  a  concise  and  available  form.  A  liberal  expenditure  has  enabled  the 
publisher  to  render  the  mechanical  portion  of  the  work  worthy  of  the  high  literary 
standard  attained  by  these  books. 

Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see  next  page  for  List). 


Saunders'  New  Series  of  Manuals* 


VOLUMES   PUBLISHED. 

PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.M.,  M.D.,  Professor  of  Physiology 
and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long  Island  College  Hospital ; 
Director  of  Physiology  in  the  Hoagland  Laboratory,  etc.     Illustrated.     Cloth,  $1.25  net. 

SURGERY,  General  and  Operative.  By  John  Chalmers  DaCosta,  M.D.,  Clini- 
cal Professor  of  Surgery,  Jefferson  Medical  College,  Philadelphia;  Surgeon  to  the 
Philadelphia  Hospital,  etc.  Second  edition,  thoroughly  revised  and  greatly  enlarged. 
Octavo,  911  pages,  profusely  illustrated.      Cloth,  $4.00  net ;   Half  Morocco,  $5.00  net. 

DOSE=BOOK    AND    MANUAL    OF    PRESCRIPTI0N=WRIT1NG.      By   E.    Q. 

Thornton,   M.D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia.    Illustrated.     Cloth,  $1.25  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's  Hospital  and 
to  the  New  York  German  Polildinik,  etc.     Illustrated.     Cloth,  $1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.D.  Professor  of  Insti- 
tutes of  Medicine  and  Medical  Jurisprudence  in  the  Jefferson  Medical  College  of  Phila- 
delphia.    Illustrated.     Cloth,  $1.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James  Nevins  Hyde,  M.D., 
Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  Montgomery,  M.D., 
Lecturer  on  Dermatology  and  Genito-Urinary  Diseases  in  Rush  Medical  College, 
Chicago.      Profusely  illustrated.      Cloth,  $2.50  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.D.,  Professor  of 
Practice  in  the  Woman's  Medical  College  of  the  New  York  Infirmary;  Instructor  in 
Physical  Diagnosis  in  the  Medical  Department  of  Columbia  College,  etc.  Illustrated. 
Cloth,  #2.50  net. 

MANUAL  OF  ANATOMY.  By  Irving  S.  Haynes,  M.D.,  Adjunct  Professor  of 
Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department  of  the  New  York 
University,  etc.     Beautifully  illustrated.      Cloth,  $2.50  net. 

MANUAL  OF  OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania  ;  Chief  of  Gynecological  Dis- 
pensary, Pennsylvania  Hospital,  etc.     Profusely  illustrated.     Cloth,  $2.50  net. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.  R.  C.  S.,  Assistant  Surgeon  to 
Middlesex  Hospital  and  Surgeon  to  Chelsea  Hospital,  London;  and  Arthur  E. 
Giles,  M.D. ,  B.  Sc.  Lond.,  F.R.C.S.  Edin.,  Assistant  Surgeon  to  Chelsea  Hospital, 
London.     Handsomely  illustrated.     Cloth,  32.50  net. 


VOLUMES  IN  PREPARATION. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.D.,  Clinical  Professor  of  Nervous 
Diseases,  Medico-Chirurgical  College,  Philadelphia ;  Pathologist  to  the  Orthopaedic 
Hospital  and  Infirmary  for  Nervous  Diseases ;  Visiting  Physician  to  the  St.  Joseph 
Hospital,  etc. 

***  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully-prepared  works 
on  various  subjects  by  prominent  specialists. 


Pamphlet  containing  specimen  pages,  etc.  sent  free  upon  application. 


26  Medical  Publications  of  W.  JB.  Saunders. 

SAUNDBY'S  RENAL  AND  URINARY  DISEASES. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby, 
M.D.  Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and 
of  the  Royal  Medico-Chirurgical  Society  ;  Physician  to  the  General 
Hospital ;  Consulting  Physician  to  the  Eye  Hospital  and  to  the  Hos- 
pital for  Diseases  of  Women;  Professor  of  Medicine  in  Mason  College, 
Birmingham,  etc.  Octavo  volume  of  434  pages,  with  numerous  illus- 
trations and  4  colored  plates.     Cloth,  $2.50  net. 

"  The  volume  makes  a  favorable  impression  at  once.  The  style  is  clear  and  succinct. 
We  cannot  find  any  part  of  the  subject  in  which  the  views  expressed  are  not  carefully  thought 
out  and  fortified  by  evidence  drawn  from  the  most  recent  sources.  The  book  may  be  cordially 
recommended." — British  Medical  Journal. 

SAUNDERS'  MEDICAL  HAND=ATLASES. 

For  full  description  of  this  series,  with  list  of  volumes  and  prices,  see 
page  2. 

"  Lehmann  Medicinische  Handatlanten  belong  to  that  class  of  books  that  are  too  good 
to  be  appropriated  by  any  one  nation." — Journal  of  Eye,  Ear,  and  Throat  Diseases. 

"  The  appearance  of  these  works  marks  a  new  era  in  illustrated  English  medical 
works." — The  Canadian  Practitioner. 

SAUNDERS'   POCKET  MEDICAL   FORMULARY.      Fifth   Edition, 

Revised. 

By  William  M.  Powell,  M.D.,  Attending  Physician  to  the  Mercer 
House  for  Invalid  Women  at  Atlantic  City,  N.  J.  Containing  1800 
formulae  selected  from  the  best-known  authorities.  With  an  Appen- 
dix containing  Posological  Table,  Formulas  and  Doses  for  Hypo- 
dermic Medication,  Poisons  and  their  Antidotes,  Diameters  of  the 
Female  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet  List  for  Various 
Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment 
of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables  of 
Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Hand- 
somely bound  in  flexible  morocco,  with  side  index,  wallet,  and  flap. 

$i-75  net- 

"This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and,  as  the  name  of  the  author  of  each  prescription 
is  given,  is  unusually  reliable." — Medical  Record,  New  York. 

SAYRE'S  PHARMACY.     Second  Edition,  Revised. 

Essentials  of  the  Practice  of  Pharmacy.  By  Lucius  E.  Sayre, 
M.D.,  Professor  of  Pharmacy  and  Materia  Medica  in  the  University  of 
Kansas.  Crown  octavo,  200  pages.  Cloth,  $1.00;  interleaved  for 
notes,  $1.25. 

[See  Saunders'  Question-  Compends,  page  21.] 

"  The  topics  are  treated  in  a  simple,  practical  manner,  and  the  work  forms  a  very  useful 
Student's  manual." — Boston  Medical  and  Surgical  Journal. 

SCUDDER'S  FRACTURES. 

The  Treatment  of  Fractures.     By  Chas.  L.  Scudder,  M.D.,  As- 
sistant   in    Clinical  and  Operative  Surgery,  Harvard  Medical  School. 
Octavo,  400  pages,  with  nearly  600  original  illustrations.     Cloth,  $ 
net. 


Medical  Publications  of  W.  B.  Saunders.  27 

SEMPLE'S  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 
Essentials  of    Legal    Medicine,  Toxicology,  and   Hygiene.     By 

C.  E.  Armand  Semple,  B.  A.,  M.  B.  Cantab.,  M.  R.  C.  P.  Lond., 
Physician  to  the  Northeastern  Hospital  for  Children,  Hackney,  etc. 
Crown  octavo,  2 1 2  pages ;  130  illustrations.  Cloth,  $1.00;  interleaved 
for  notes,  $1.25. 

[See  Saunders'  Question-  Compends,  page  21.] 

"  No  general  practitioner  or  student  can  afford  to  be  without  this  valuable  work.  The 
subjects  are  dealt  with  by  a  masterly  hand." — London  Hospital  Gazette. 

SEMPLE'S  PATHOLOGY  AND  MORBID  ANATOMY. 

Essentials    of    Pathology    and    Morbid    Anatomy.      By  C.   E. 

Armand  Semple,  B.A.,  M.B.  Cantab.,  M.R.C.P.  Lond.,  Physician  to 
the  Northeastern  Hospital  for  Children,  Hackney,  etc.     Crown  octavo, 
174  pages;  illustrated.      Cloth,  $1.00;  interleaved  for  notes,  $1.25. 
[See  Saunders'  Question- Compends,  page  21.] 

"  Should  take  its  place  among  the  standard  volumes  on  the  bookshelf  of  both  student 
and  practitioner." — London  Hospital  Gazette. 

SENN'S  GENITOURINARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito=Urinary  Organs,  Male  and  Female. 

By  Nicholas  Senn,  M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of 
Surgery  and  of  Clinical  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  320  pages,  illustrated.     Cloth,  $3.00  net. 

"  An  important  book  upon  an  important  subject,  and  written  by  a  man  of  mature  judg- 
ment and  wide  experience.  The  author  has  given  us  an  instructive  book  upon  one  of  the 
most  important  subjects  of  the  day." — Clinical  Reporter. 

"  A  work  which  adds  another  to  the  many  obligations  the  profession  owes  the  talented 
author." — Chicago  Medical  Recorder. 

SENN'S  SYLLABUS  OF  SURGERY. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged 
in  conformity  with  "  An  American  Text=Book  of  Surgery."    By 

Nicholas  Senn,  M.D.,  Ph.D.,  Professor  of  the  Practice  of  Surgery  and 
of  Clinical  Surgery  in  Rush  Medical  College,  Chicago.     Cloth,  $2.00. 

"  This  syllabus  will  be  found  of  service  by  the  teacher  as  well  as  the  student,  the  work 
being  superbly  done.  There  is  no  praise  too  high  for  it.  No  surgeon  should  be  without 
it." — New  York  Medical  Times. 

SENN'S  TUMORS. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  N.  Senn, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Rush  Medical  College ;  Professor  of  Surgery,  Chicago  Polyclinic ; 
Attending  Surgeon  to  Presbyterian  Hospital :  Surgeon-in-Chief,  St. 
Joseph's  Hospital,  Chicago.  Octavo  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  New  and  Revised  Edi- 
tion in  Preparation. 

"  The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language 
for  some  years.  The  book  is  handsomely  illustrated  and  printed,  and  the  author  has  given  a 
notable  and  lasting  contribution  to  surgery." — -Journal  op  the  American  Medical  Association. 


28  Medical  Publications  of  W.  B.  Saunders. 

SHAW'S  NERVOUS  DISEASES  AND  INSANITY.  Third  Edition, 
Revised. 
Essentials  of  Nervous  Diseases  and  Insanity.  By  John  C. 
Shaw,  M.D.,  Clinical  Professor  of  Diseases  of  the  Mind  and  Nervous 
System,  Long  Island  College  Hospital  Medical  School ;  Consulting 
Neurologist  to  St.  Catherine's  Hospital  and  to  the  Long  Island  College 
Hospital.  Crown  octavo,  186  pages;  48  original  illustrations.  Cloth, 
$1.00;  interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Commends,  page  21.] 

"Clearly  and  intelligently  written." — Boston  Medical  and  Surgical  Journal. 
"There  is  a  mass  of  valuable  material  crowded  into  this  small  compass." — American 
Medico-  Swgical  Bulletin. 

STARR'S  DIETS  FOR  INFANTS  AND  CHILDREN. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.     By 

Louis  Starr,  M.D.,  Editor  of  "An  American  Text-Book  of  the 
Diseases  of  Children."  230  blanks  (pocket-book  size),  perforated 
and  neatly  bound  in  flexible  morocco.      $1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant  life  ;  each 
blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food,  the  latter  directions  being 
left  for  the  physician.  After  the  seventh  month,  modifications  being  less  necessary,  the  diet 
lists  are  printed  in  full.      Formulas  for  the  preparation  of  diluents  and  foods  are  appended. 

STELW AGON'S  DISEASES  OF  THE  SKIN.  Fourth  Ed.,  Revised. 
Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stelwagon, 
M.D.,  Clinical  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia;  Dermatologist  to  the  Philadelphia  Hospital; 
Physician  to  the  Skin  Department  of  the  Howard  Hospital,  etc. 
Crown  octavo,  276  pages;  88  illustrations.  Cloth,  $1.00  net;  inter- 
leaved for  notes,  $1.25  net. 

[See  Saunders'  Question- Commends,  page   21.] 
"  The  best  student's  manual  on  skin  diseases  we  have  yet  seen." — Times  and  Register. 

STENGEL'S  PATHOLOGY.      Second  Edition. 

A  Text=Book  of  Pathology.  By  Alfred  Stengel,  M.D.,  Professor 
of  Clinical  Medicine  in  the  University  of  Pennsylvania;  Physician  to 
the  Philadelphia  Hospital  ;  Physician  to  the  Children's  Hospital,  etc. 
Handsome  octavo  volume  of  848  pages,  with  nearly  400  illustrations, 
many  of  them  in  colors.  Cloth,  $4.00  net;  Half  Morocco,  $5.00 
net. 

STEVENS'   MATERIA   MEDICA   AND   THERAPEUTICS.      Second 
Edition,  Revised. 
A  Manual  of   Materia   Medica   and  Therapeutics.      By  A.  A. 

Stevens,  A.M.,  M.D.,  Lecturer  on  Terminology  and  Instructor  in 
Phvsical  Diagnosis  in  the  University  of  Pennsylvania;  Professor  of 
Pathology  in  the  Woman's  Medical  College  of  Pennsylvania.  Post- 
octavo,  445  pages.     Flexible  leather,  $2.25. 

•'The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work 
and,  while  intended  particularly  for  the  use  of  students,  it  will  be  found  a  reliable  guide  and 
sufficiently  comprehensive  for  the  physician  in  practice. "—  University  Medical  Magazine. 


Medical  Publications  of  W.  B.  Saunders.  29 


STEVENS'  PRACTICE  OF  MEDICINE.     Fifth  Edition,  Revised. 
A  Manual  of  the  Practice  of  Medicine.     By  A.  A.  Stevens,  A.  M., 

M.  D.,  Lecturer  on  Terminology  and  Instructor  in  Physical  Diagnosis 
in  the  University  of  Pennsylvania;  Professor  of  Pathology  in  the 
Woman's  Medical  College  of  Pennsylvania.  Specially  intended  for 
students  preparing  for  graduation  and  hospital  examinations.  Post- 
octavo,  519  pages;   illustrated.     Flexible  leather,  $2.00  net. 

"  The  frequency  with  which  new  editions  of  this  manual  are  demanded  bespeaks  its 
popularity.  It  is  an  excellent  condensation  of  the  essentials  of  medical  practice  for  the 
student,  and  maybe  found  also  an  excellent   reminder  for  the  busy  physician." Buffalo 

Medical  Journal. 

STEWART'S  PHYSIOLOGY.      Third  Edition,  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For 
Students  and  Practitioners.  By  G.  N.  Stewart,  M.A.,  M.D., 
D.Sc,  lately  Examiner  in  Physiology,  University  of  Aberdeen,  and 
of  the  New  Museums,  Cambridge  University;  Professor  of  Physiology 
in  the  Western  Reserve  University,  Cleveland,  Ohio.  Octavo  volume 
of  848  pages;  300  illustrations  in  the  text,  and  5  colored  plates. 
Cloth,  $3.75  net. 

"  It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deserves  to  do  so.  It  is  one 
of  the  very  best  English  text-books  on  the  subject." — London  Lancet. 

"Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so 
nearly  comes  up  to  the  ideal  as  does  Prof.  Stewart's  volume." — British  Medical  Journal. 

STEWART  AND  LAWRANCE'S  MEDICAL  ELECTRICITY. 

Essentials  of  Medical  Electricity.  By  D.  D.  Stewart,  M.D., 
Demonstrator  of  Diseases  of  the  Nervous  System  and  Chief  of  the 
Neurological  Clinic  in  the  Jefferson  Medical.  College;  and  E.  S. 
Lawrance,  M.D.,  Chief  of  the  Electrical  Clinic  and  Assistant  Demon- 
strator of  Diseases  of  the  Nervous  System  in  the  Jefferson  Medical 
College,  etc.  Crown  octavo,  158  pages;  65  illustrations.  Cloth, 
$1.00;  interleaved  for  notes,  $1.25. 

[See  Saunders'  Question-  Compends,  page  21.] 

"  Throughout  the  whole  brief  space  at  their  command  the  authors  show  a  discriminating 
knowledge  of  their  subject." — Medical  ATews. 

STONEY'S  NURSING.     Second  Edition,  Revised. 

Practical  Points  in  Nursing.     For  Nurses  in  Private  Practice, 

By  Emily  A.  M.  Stoney,  Graduate  of  the  Training-School  for  Nurses, 
Lawrence,  Mass.;  late  Superintendent  of  the  Training-School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  illustrated 
with  73  engravings  in  the  text,  and  8  colored  and  half-tone  plates. 
Cloth,  $1.75  net. 

"  There  are  few  books  intended  for  non -professional  readers  which  can  be  so  cordially 
endorsed  by  a  medical  journal  as  can  this  one." — Therapeutic  Gazette. 

"  This  is  a  well-written,  eminently  practical  volume,  which  covers  the  entire  range  of 
private  nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to 
meet  the  various  emergencies  which  may  arise,  and  how  to  prepare  everything  ordinarily 
needed  in  the  illness  of  her  patient." — American  Journal  of  Obstetrics  and  Diseases  of 
Women  and  Children. 

"  It  is  a  work  that  the  physician  can  place  in  the  hands  of  his  private  nurses  with  the 
assurance  of  benefit." — Ohio  Medical  Journal. 


30  Medical  Publications  of  W.  B.  Saunders, 

STONEY'S   MATERIA   MEDICA    FOR   NURSES. 

Materia  Medica  for  Nurses.  By  Emily  A.  M.  Stoney,  Graduate  of 
the  Training-School  for  Nurses,  Lawrence,  Mass.  ;  late  Superintendent 
of  the  Training-School  for  Nurses,  Carney  Hospital,  South  Boston,  Mass. 
Handsome  octavo  volume  of  306  pages.     Cloth,  $1.50  net. 

The  present  book  differs  from  other  similar  works  in  several  features,  all  of  which  are 
intended  to  render  it  more  practical  and  generally  useful.  The  general  plan  of  the  contents 
follows  the  lines  laid  down  in  training-schools  for  nurses,  but  the  book  contains  much  use- 
ful matter  not  usually  included  in  works  of  this  character,  such  as  Poison-emergencies, 
Ready  Dose-list,  Weights  and  Measures,  etc.,  as  well  as  a  Glossary,  defining  all  the  terms 
used  in  Materia  Medica,  and  describing  all  the  latest  drugs  and  remedies,  which  have  been 
generally  neglected  by  other  books  of  the  kind. 

SUTTON  AND  GILES'  DISEASES  OF  WOMEN. 

Diseases  of  Women.  By  J.  Bland  Sutton,  F.R.C.S.,  Assistant 
Surgeon  to  Middlesex  Hospital,  and  Surgeon  to  Chelsea  Hospital, 
London;  and  Arthur  E.  Giles,  M.D.,  B.Sc.  Lond.,  F.R. C.S.  Edin., 
Assistant  Surgeon  to  Chelsea  Hospital,  London.  436  pages,  hand- 
somely illustrated.      Cloth,  $2.50  net. 

"The  text  has  been  carefully  prepared.  Nothing  essential  has  been  omitted,  and  its 
teachings  are  those  recommended  by  the  leading  authorities  of  the  day." — Journal  of  the 
American  Medical  Association. 

THOMAS'S  DIET  LISTS.     Second  Edition,  Revised. 

Diet  Lists  and  Sick=Room  Dietary.  By  Jerome  B.  Thomas, 
M.D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and 
Children  and  to  the  Newsboys'  Home  ;  Assistant  Visiting  Physician 
to  the  Kings  County  Hospital.      Cloth,  $1.50.     Send  for  sample  sheet. 

THORNTON'S  DOSE=BOOK  AND  PRESCRIPTION=WRITING. 

Dose=Book  and  Manual  of    Prescription=Writing.       By   E.    Q. 

Thornton,  M.D.,  Demonstrator  of  Therapeutics,  Je'fferson  Medical 
College,  Philadelphia.      334  pages,  illustrated.      Cloth,  $1.25  net. 

"Full  of  practical  suggestions;  will  take  its  place  in  the  front  rank  of  works  of  this 
sort." — Aledical  Record,  New  York. 

VAN  VALZAH  AND  NISBET'S  DISEASES  OF  THE  STOMACH. 
Diseases  of  the  Stomach.  By  William  W.  Van  Valzah,  M.D., 
Professor  of  General  Medicine  and  Diseases  of  the  Digestive  System 
and  the  Blood,  New  York  Polyclinic;  and  J.  Douglas  Nisbet,  M.D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive 
System  and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674 
pages,  illustrated.      Cloth,  $3.50  net. 

"  Its  chief  claim  lies  in  its  clearness  and  general  adaptability  to  the  practical  needs  of 
the  general  practitioner  or  student.  In  these  relations  it  is  probably  the  best  of  the  recent 
special  works  on  diseases  of  the  stomach." — Chicago  Clinical  Review. 

VECKI'S   SEXUAL  IMPOTENCE. 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor 
G.  Vecki,  M.D.  From  the  second  German  edition,  revised  and  en- 
larged.    Demi-octavo,  291  pages.      Cloth,  $2.00  net. 

The  subject  of  impotence  has  seldom  been  treated  in  this  country  in  the  truly  scientific 
spirit  that  it  deserves.  Dr.  Vecki's  work  has  long  been  favorably  known,  and  the  German 
book  has  received  the  highest  consideration.  This  edition  is  more  than  a  mere  translation, 
for,  although  based  on  the  German  edition,  it  has  been  entirely  rewritten  in  English. 


Medical  Publications  of  W.  B.  Saunders.  31 


VIERORDT'S  MEDICAL  DIAGNOSIS.  Fourth  Edition,  Revised. 
Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medi- 
cine at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  fifth  enlarged  German  edition,  with  the  author's  permission, 
by  Francis  H.  Stuart,  A.  M.,  M.  D.  Handsome  royal  octavo  volume 
of  603  pages;  194  fine  wood-cuts  in  text,  many  of  them  in  colors. 
Cloth,  $4.00  net;  Sheep  or  Half  Morocco,  $5.00  net. 

"  A  treasury  of  practical  information  which  will  be  found  of  daily  use  to  every  busy 
practitioner  who  will  consult  it." — C.  A.  LlNDSLEY,  M.D.,  Professor  of  the  Theory  and 
Practice  of  Medici 'ne,   Yale  University. 

"  Rarely  is  a  book  published  with  which  a  reviewer  can  find  so  little  fault  as  with  the 
volume  before  us.  Each  particular  item  in  the  consideration  of  an  organ  or  apparatus,  which 
is  necessary  to  determine  a  diagnosis  of  any  disease  of  that  organ,  is  mentioned ;  nothing 
seems  forgotten.  The  chapters  on  diseases  of  the  circulatory  and  digestive  apparatus  and 
nervous  system  are  especially  full  and  valuable.  The  reviewer  would  repeat  that  the  book  is 
one  of  the  best — probably  the  best — which  has  fallen  into  his  hands." — University  Medical 
Magazine. 

WARREN'S  SURGICAL  PATHOLOGY  AND  THERAPEUTICS. 
Second   Edition. 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.  D.,  LL.D.,  Professor  of  Surgery,  Medical  Department  Harvard  Uni- 
versity ;  Surgeon  to  the  Massachusetts  General  Hospital,  etc.  Handsome 
octavo  volume  of  832  pages;  136  relief  and  lithographic  illustrations, 
33  of  which  are  printed  in  colors  ;  with  an  Appendix  devoted  to  the 
Scientific  Aids  to  Surgical  Diagnosis,  and  a  series  of  articles  on  Re- 
gional Bacteriology.      Cloth,  $5.00  net;   Half  Morocco,  $6.00  net. 

"There  is  the  work  of  Dr.  Warren,  which  I  think  is  the  most  creditable  book  on 
Surgical  Pathology,  and  the  most  beautiful  medical  illustration  of  the  bookmaker's  art,  that 
has  ever  been  issued  from  the  American  press." — Dr.  Roswell  Park,  in  the  Harvard 
Graduate  Magazine. 

"  A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without 
exception,  from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work 
of  this  kind.  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their  coloring 
and  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the  barrel 
of  a  microscope  at  a  well-mounted  section." — Annals  of  Surgery. 

WOLFF  ON  EXAMINATION  OF  URINE. 

Essentials  of  Examination  of  Urine.  By  Lawrence  Wolff,  M.D., 
Demonstrator  of  Chemistry,  Jefferson  Medical  College,  Philadelphia, 
etc.  Colored  (Vogel)  urine  scale  and  numerous  illustrations.  Crown 
octavo.      Cloth,  75  cents. 

[See  Saunders'   Question- Compends,  page   21.] 

"  A  very  good  work  of  its  kind — very  well  suited  to  its  purpose." — Times  and  Register. 

WOLFF'S  MEDICAL  CHEMISTRY.     Fifth  Edition,  Revised. 

Essentials    of    Medical    Chemistry,   Organic    and    Inorganic. 

Containing  also  Questions  on  Medical  Physics,  Chemical  Physiology, 
Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Lawrence 
Wolff,  M.D.,  Demonstrator  of  Chemistry,  Jefferson  Medical  College, 
Philadelphia,  etc.  Crown  octavo,  222  pages.  Cloth,  $1.00  net;  inter- 
leaved for  notes,  #1.25  net. 

[See  Saunders''  Question- Compends,  page   21.] 

"  The  scope  of  this  work  is  certainly  equal  to  that  of  the  best  course  of  lectures  on 
Medical  Chemistry." — Pharmaceutical  Era. 


CLASSIFIED    LIST 


Medical  Publications 


W.  B.  SAUNDERS, 

925  Walnut  Street,  Philadelphia. 


ANATOMY,  EMBRYOLOGY, 
HISTOLOGY. 

Clarkson — A  Text-Book  of  Histology,  1 1 
Haynes — A  Manual  of  Anatomy,  ...15 

Heisler — A  Text- Book  of  Embryology,  15 

Nancrede — Essentials  of  Anatomy,  .    .  20 
Nancrede — Essentials  of  Anatomy  and 

Manual  of  Practical  Dissection,  ...  20 

Semple — Essentials  of  Pathology,     .    .  27 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology,  ...  S 
Crookshank — A  Text-Book  of  Bacteri- 
ology,    12 

Frothingham  —  Laboratory  Guide,    .    .  13 
Levy  and  Klemperer's  Clinical  Bacte- 
riology,    17 

Mallory    and    Wright  —  Pathological 

Technique, 18 

McFarland — Pathogenic  Bacteria,    .    .  iq 

CHARTS,  DIET=LISTS,  ETC. 

Griffith — Infant's  Weight  Chart,    ...  14 

Hart — Diet  in  Sickness  and  in  Health,  .  15 

Keen — Operation  Blank, 17 

Laine — Temperature  Chart, 17 

Meigs — Feeding  in  Early  Infancy,     .    .  19 

Starr — Diets  for  Infants  and  Children,  .  28 

Thomas— Diet-Lists, 30 

CHEMISTRY  AND  PHYSICS. 

Brockway — Essentials  of  Medical  Phys- 
ics,    9 

Wolff — Essentials  of  Medical  Chemistry,  31 

CHILDREN. 

An  American  Text-Book  of  Diseases 

of  Children, 5 

Griffith — Care  of  the  Baby 14 

Griffith — Infant's  Weight  Chart,  ...  14 

Meigs — Feeding  in  Early  Infancy,    .    .  19 

Powell — Essentials  of  Dis.  of  Children,  21 

Starr — Diets  for  Infants  and  Children,  .  28 

DIAGNOSIS. 

Cohen  and  Eshner — Essentials  of  Di- 
agnosis,     11 

Corwin — Physical  Diagnosis,      ....  11 

Macdonald — Surgical    Diagnosis    and 

Treatment,      18 

Vierordt — Medical  Diagnosis 31 

DICTIONARIES. 

Dorland — Pocket  Dictionary,     ....  12 

Keating — Pronouncing  Dictionary,    .    .  16 

Morten — Nurse's  Dictionary,      ....  20 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text-Book  of  Diseases 

of  the  Eye,  Ear,  Nose,  and  Throat,  .  5 
De  Schweinitz — Diseases  of  the  Eye, .  12 
Gleason — Essentials  of  Dis.  of  the  Ear,  13 
Jackson — Manual  of  Diseases  of  Eye,  .  16 
Jackson   and    Gleason — Essentials  of 

Diseases  of  the  Eye,  Nose,  and  Throat,  16 
Kyle — Diseases  of  the  Nose  and  Throat,  17 

GENITOURINARY. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 6 

Hyde  and  Montgomery — Syphilis  and 

the  Venereal  Diseases, 15 

Martin — Essentials   of  Minor   Surgery, 

Bandaging,  and  Venereal  Diseases,  .  18 
Saundby — Renal  and  Urinary  Diseases,  26 
Senn — Genito-Urinary  Tuberculosis,  .  27 
Vecki — Sexual  Impotence, 30 

GYNECOLOGY. 

American  Text- Book  of  Gynecology,  6 

Cragin — Essentials  of  Gynecology,    .    .  II 

Garrigues — Diseases  of  Women,  ...  13 

Long — Syllabus  of  Gynecology,     ...  17 

Penrose — Diseases  of  Women,  ....  20 

Pryor — Pelvic   Inflammations,     ....  34 

Sutton  and  Giles — Diseases  of  Women,  30 

MATERIA  MEDICA,  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

An  American  Text-Book  of  Applied 

Therapeutics, 5 

Butler — Text-Book  of  Materia  Medica, 

Therapeutics  and  Pharmacology,  ...  10 
Cerna — Notes  on  the  Newer  Remedies,  10 
Griffin — Materia  Med.  and  Therapeutics,  14 
Morris — Essentials  of   Materia   Medica 

and  Therapeutics, 19 

Saunders'  Pocket  Medical  Formulary,  26 
Sayre — Essentials  of  Pharmacy,  ...  26 
Stevens — Essentials  of  Materia  Medica 

and  Therapeutics, 28 

Stoney — Materia  Medica  for  Nurses,  .  .  30 
Thornton — I  Jose- Book  and  Manual  of 

Prescription-Writing, 30 

MEDICAL   JURISPRUDENCE    AND 
TOXICOLOGY. 

Chapman — Medical  Jurisprudence  and 
Toxicology, 10 

Semple — Essentials  of  Legal  Medicine, 
Toxicology,  and  Hygiene, 27 


Medical  Publications  of  W.  B.  Saunders. 


33 


NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Burr — Nervous  Diseases, 9 

Chapin — Compendium  of  Insanity,  .  .  10 
Church    and    Peterson — Nervous  and 

Mental  Diseases, 10 

Shaw — Essentials  of  Nervous  Diseases 

and  Insanity, 28 

NURSING. 

An  American  Text-Book  of  Nursing,  31 

Griffith— The  Care  of  the  Baby,    ...  14 

Hampton — Nursing, '4 

Hart — Diet  in  Sickness  and  in  Health,  15 

Meigs — Feeding  in  Early  Infancy,    .    .  19 

Morten — Nurse's  Dictionary 20 

Stoney — Materia  Medica  for  Nurses,  .    .  30 

Stoney — Practical  Points  in  Nursing,    .  29 

OBSTETRICS. 

An  American  Text-Book  of  Obstetrics, 
Ashton — Essentials  of  Obstetrics, 
Boisliniere — Obstetric  Accident-, 
Dorland — Manual  of  Obstetrics, 
Hirst — Text- Book  of  Obstetrics, 
Norris — Syllabus  of  Obstetrics,  . 

PATHOLOGY. 

An  American  Text-Book  of  Pathology, 

Mallory  and  Wright — Pathological 
Technique, 

Semple — Essentials  of  Pathology  and 
Morbid  Anatomy, 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 

Stengel — Text-Book  of  Pathology,    .    . 

Warren — Surgical  Pathology  and  Thera- 
peutics,     

PHYSIOLOGY. 

An  American  Text-Book  of  Physi- 
ology,  

Hare — Essentials  of  Physiology,  .  .  . 
Raymond — Manual  of  Physiology,  .  . 
Stewart — Manual  of  Physiology,  .    .    . 

PRACTICE  OF  MEDICINE. 

An  American  Text-Book  of  the  The- 
ory and  Practice  of  Medicine,  .... 

An  American  Year-Book  of  Medicine 
and  Surgery, 

Anders — Text-Book  of  the  Practice  of 
Medicine, 

Lockwood — Manual  of  the  Practice  of 
Medicine, .... 

Morris — Essentials  of  the  Practice  of 
Medicine, 

Stevens — Manual  of  the  Practice  of 
Medicine, 

SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 

Hyde  and  Montgomery — Syphilis  and 
the  Venereal  Diseases, 


Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,    .    18 

Pringle — Pictorial  Atlas  of  Skin  Dis- 
eases and  Syphilitic  Affections,    ...    21 

Stelwagon — Essentials  of  Diseases  of 
the  Skin, 28 

SURGERY. 

An  American  Text-Book  of  Surgery,  7 
An  American  Year-Book  of  Medicine 

and  Surgery, 8 

Beck — -Fractures, 9 

Beck — Manual  of  Surgical  Asepsis,  .    .  9 

DaCosta — Manual  of  Surgery,  .    ...  12 

International  Text-Book  of  Surgery,  .  15 

Keen— Operation  Blank, 17 

Keen — The  Surgical  Complications  and 

Sequels  of  Typhoid  Fever, 17 

Macdonald — Surgical    Diagnosis    and 

Treatment, 18 

Martin — Essentials   of    Minor  Surgery, 

Bandaging,  and  Venereal  Diseases,     .  18 

Martin — Essentials  of  Surgery,  ....  18 

Moore — Orthopedic  Surgery, 19 

Nancrede — Principles  of  Surgery,    .    .  20 

Pye — Bandaging  and  Surgical  Dressing,  21 

Scudder — Treatment  of  Fractures,    .    .  26 

Senn — Genito-Urinary  Tuberculosis,     .  27 

Senn— Syllabus  of  Surgery, 27 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, .    .  27 

Warren — Surgical  Pathology  and  Ther- 
apeutics,        31 

URINE  AND  URINARY  DISEASES. 

Saundby — Renal  and  Urinary  Diseases,  26 
I  Wolff — Essentials    of    Examination    of 
Urine, 31 

MISCELLANEOUS. 

Abbott — Hygiene  of  Transmissible  Dis- 
eases,        ° 

Bastin — Laboratory  Exercises  in  Bot- 
any,            9 

Gould  and  Pyle — Anomalies  and  Curi- 
osities of  Medicine, 13 

Grafstrom — Massage,     .......     14 

Keating — How   to    Examine    for   Life 
Insurance,      .......    o    -    .  16 

Rowland    and    Hedley — Archives   of 

the  Roentgen  Ray, 2r 

Saunders'  Medical  Hand-Atlases.  .2,  3,  4 
Saunders'  New  Series  of  Manuals,  24,  25 
Saunders'  Pocket  Medical  Formulary,  26 
Saunders'  Question-Compends,  .  .  22,  23 
Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 27 

Stewart  and  Lawrance — Essentials  of 

Medical  Electricity, 29 

Thornton — Dose-Book  and  Manual  of 

Prescription-Writing, 3° 

Van  Valzah  and  Nisbet— Diseases  of 
the  Stomach, 3° 


Some  of  the  Books  in  Preparation  for 
Publication  during  1900. 


AMERICAN  Text-Book  of  Pa- 
thology. 

Edited  by  Ludvig  Hektoen,  M.  D.,  Pro- 
fessor of  Pathology,  Rush  Medical  College, 
Chicago;  and  David  Riesman,  M.  D.,  De- 
monstrator of  Pathological  Histology,  Uni- 
versity of  Pennsylvania. 

AMERICAN  Text-Book  of  Legal 
Medicine  and  Toxicology. 

Edited  by  Frederick  Peterson,  M.  D  , 
Chief  of  Clinic,  Nervous  Department,  College 
of  Physicians  and  Surgeons,  New  York  City  ; 
and  Walter  S.  Haines,  M.  D.,  Professor  of 
Chemistry,  Pharmacy,  and  Toxicology,  Rush 
Medical  College,  Chicago. 

BOHM,  DAV1DOFF,  and  HU- 
BER — A  Text-Book  of  Human 
Histology. 

Including  Microscopic  Technic.  By 
Dr.  A.  A.  Bohm  and  Dr.  M.  von  Davidoff, 
of  the  Anatomical  Institute  of  Munich,  and 
G.  C.  Hubkr,  M.  D.,  Junior  Professor  of  Anat- 
omy and  Histology,  University  of  Michigan, 
Ann  Arbor. 

EICHHORST  — A  Text-Book  of 
the  Practice  of  Medicine. 

By  Dr.  Herman  Eichiiorst,  Professor  of 
Special  Pathology  and  Therapeutics  and  Di- 
rector of  the  Medical  Clinic,  University  of 
Zurich.  Translated  and  edited  by  Augustus 
A.  ESHNER,  M.  D.,  Professor  of  Clinical  Medi- 
cine in  the  Philadelphia  Polyclinic. 

FRIEDRICH  —  Rhinology,  La- 
ryngology, and  Otology  in 
their  Relations  to  General 
Medicine. 

By  Dr.  E.  P.  Friedrich,  of  the  Univer- 
sity of  Leipsig.  Edited  by  H.  Holbrook 
CURTIS,  M.  D.,  Consulting  Surgeon  to  the 
New  York  Nose  and  Throat  Hospital. 

McFARLAND  — A  Text-Book  of 
Pathology. 

By  Joseph  McFarland,  M.D.,  Professor 
of  Pathology  and  Bacteriology,  Medico-Chi- 
rurgical  College,  Philadelphia. 

OGDEN  —  Clinical  Examination 
of  the  Urine. 

By  J.  Bergen  Ogden,  M.D.,  Assistant  in 

Chemistry,  Harvard  Medical  School. 


PYLE  — A  Manual  of  Personal 
Hygiene. 

Edited  by  Walter  L.  Pyle,  M.  D.,  Assis- 
tant Surgeon  to  Wills'  Eye  Hospital,  Philada. 

SALINGER  AND  KALTEYER— 
Modern  Medicine. 

By  Julius  L.  Salinger,  M.  D.,  Demon- 
strator of  Clinical  Medicine,  Jefferson  Medi- 
cal College  ;  Chief  of  Medical  Clinic,  Jeffer- 
son College  Hospital ;  Attending  Physician  to 
Philadelphia  Hospital;  and  F.  J.  Kalteyer, 
M.  D.,  Assistant  Demonstrator  of  Clinical 
Medicine,  Jefferson  Medical  College;  Assis- 
tant Pathologist  to  Philadelphia  Hospital. 

SCUDDER  —  The  Treatment  of 
Fractures. 

By  Charles  L.  Scudder,  M.  D.,  Assistant 
in  Clinical  and  Operative  Surgery,  Harvard 
University.     See  page  26. 

SENN — Practical  Surgery. 

By  Nicholas  Senn,  M.  D.,  Ph.  D.,  LL.  D., 
Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery,  Rush  Medical  College,  Chi- 
cago. Octavo  volume  of  about  800  pages, 
profusely  illustrated. 

The  Pathology  and  Treatment 
of  Tumors. 

By  Nicholas  Senn,  M.  D.,  Ph.  D.,  LL.D., 
Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery,  Rush  Medical  College,  Chi- 
cago. A  New  and  Thoroughly  Revised  Edi- 
tion in  preparation. 

STENGEL  AND  WHITE— The 
Blood  in  its  Clinical  and  Patho- 
logical Relations. 

By  Alfred  Stengel,  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsyl- 
vania; and  C.  Y.  White,  M.  D.,  Instructor  in 
Clinical  Medicine  University  of  Pennsylvania-* 

STEVENS  — The  Physical  Diag- 
nosis of  Diseases  of  the  Chest. 

By  A.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer 
on  Terminology,  and  Instructor  in  Physical 
Diagnosis,  University  of  Pennsylvania. 

STONEY— Surgical  Technic  for 
Nurses. 

By  Emily  A.  M.  Stoney,  late  Superin- 
tendent of  the  Training  Schools  for  Nurses, 
Carney  Hospital,  SouthBoston,  Mass. 


RD101 
Beck 


B38 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RD  101  B38  C.1 

Fractures. . 


2002103966 


